Health inspection·October 13, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure a transfer notice was provided to Resident 39 and Resident 39's representative and a copy of the discharge notice was sent to the Office of the State Long Term Care Ombudsman as required, for a census of 66. This failure had the potential to result in residents not being protected from unnecessary transfers and not having access to an advocate who can inform them of their options and rights. Findings: Resident 39 was admitted to the facility in mid 2022 with diagnoses that included sepsis (the body's life-threatening response to infection). Review of Resident 39's Progress Notes dated, 6/19/22, indicated, Resident found at approximately 1330 with tachypnea [abnormally rapid breathing] and body shakes. [medical transportation company] called . until ambulance arrived . [medical transportation company] left with resident . Report called into [hospital] . Review of Resident 39's eINTERACT Transfer Form, dated 6/19/22, indicated Resident 39 was sent to a hospital for an unplanned transfer. In an interview with the Director of Nursing (DON) on 10/12/22 at 11:46 a.m., the DON stated a notice of transfer during hospitalization were not provided to residents and copies of the aforementioned notice were not sent to the ombudsman. Review of an undated facility policy titled, Making an Emergency Transfer or Discharge, indicated, . If it is determined that the discharge is not resident initiated, a notification will be sent to the Ombudsman's Office as well as to the resident and/or the resident's responsible party. Page 1 of 8 555744 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

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 observation, interview, and record review, the facility failed to ensure quality of care was provided for two residents (Resident 40 and Resident 27) for a census of 66 when: Residents Affected - Few 1. Resident 40's tube feeding order was not clarified with the physician, and, 2. Resident 27 did not recieve treatment and care for a wound on his right foot in accordance with the plan of care and professional standards. These failures had the potential for Resident 40 to not receive an adequate amount of nutrition as ordered and had the potential for the worsening of Resident 27's wound on his right foot. Findings: 1. Resident 40 was admitted to the facility in mid 2021 with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen) . Review of the Physician Orders from Resident 40s's hospice agency indicated an order for, . START [brand name, tube feeding formula] 1.2 CAL [calories] 60 MILLILITERS VIA G TUBE [gastrostomy tube, a tube placed through the abdomen into the stomach to deliver nutrition or medication] ONCE A DAY FOR 12 HOURS WITH 150 ML [milliliters, a unit of measurement] FREE WATER FLUSH EVERY 8 HRS [hours] . In a concurrent observation and interview with the Unit Manager (UM) on 10/10/22 at 12:33 p.m., a tube feeding bag was observed hanging next to Resident 40 with approximately 400 ml of tube feeding formula. The feeding bag was not connected to Resident 40. The feeding bag label indicated Resident 40's name, name of the formula, rate of administration (60 ml/hr), date of 10/10/22, but with no time. The UM stated resident had [brand name, tube feeding formula] 12 hours feeding at 60 ml/hr, from 6pm - 6am. The UM stated PM shift changes the bag and further stated it should have been thrown away after the feeding was completed. The UM could not explain why 10/10/22 was the date on the bag instead of when it was hung the day before (10/9/22). The UM proceeded to throw away the feeding bag with formula. The UM stated she would check Resident 40's tube feeding order. Review of the Administration History for Resident 40's Enteral Feed Order indicated the following effective dates and times of tube feeding administration: 10/10/22 - 8:49 a.m. 10/9/22 - 9:01 a.m. 10/8/22 - 10:04 a.m. 10/7/22 - 7:30 a.m. 10/6/22 - 8:33 a.m. 10/5/22 - 10:10 a.m. 555744 Page 2 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0684 10/4/22 - 9:31 a.m. Level of Harm - Minimal harm or potential for actual harm 10/3/22 - 12:07 p.m. 10/2/22 - 7:47 a.m. Residents Affected - Few 10/1/22 - 11:17 a.m. 9/30/22 - 8:32 a.m. 9/29/22 - 9:00 a.m. 9/28/22 - 10:34 a.m. 9/27/22 - 11:25 a.m. Review of Resident 40's Physician Order, created 9/26/22, indicated, [brand name, tube feeding formula] 1.2 at 60ml/hr x 12 hrs w/150mL free water flush Q 4hrs. Provides 1440 ml formula, 1728 kcal, 80g pro, 1781 ml free water . facility time code: AM Flex (7-3) . Review of Resident 40's document titled ,Order Details, dated 10/10/22 at 3:47 p.m., indicated an order for, [brand name, tube feeding formula] 1.2 at 60ml/hr x 12 hrs w/150ml free water flush q 4 hrs. Provides 1440 ml formula, 1728 kcal [kilocalories], 80g pro [protein], 1781 ml free water start TF [tube feeding] at midnight till next day at noon] . In a concurrent interview and record review with the Director of Nursing (DON) on 10/10/22 at 4 p.m., The DON stated the tube feeding order for Resident 40, dated 9/26/22, which indicated flex time, indicated the feeding could be started any time between 7-3 pm. The DON further stated the feeding order was unusual, The DON confirmed the tube feeding orders dated 9/26/22 and 10/10/22 at 3:47 p.m., did not equate to 1440 ml, and the total amount of feeding indicated in both orders were wrong. The DON stated the Registered Dietitian (RD) should have been a part of reviewing the feeding orders and clarification should have been done with the RD. Review of Resident 40's document titled, Order Details, dated 10/10/22 at 5:51 p.m., indicated an order for, [brand name, tube feeding formula] 1.2 at 60ml/hr x 12 hrs w/ 150ml free water flush q 4 hrs. Provides 720 ml formula, 864 kcl, 40g pro, 1490 ml free water . start TF [tube feeding] at midnight till next day at noon . Review of Resident 40's Registered Dietitian notes, dated 10/10/22 at 6:05 p.m., indicated, Called hospice in regards to the new TF orders that were placed. The new regimen is [brand name, tube feeding formula] 1.2 at 60ml/hr x 12 hrs w/ 150 ml free water flush q 4 hrs. which provides 720 ml formula, 864 kcal, 40 g pro, and 1490 ml free water. This will not meet her needs as she needs - 1400-1600 kcal and -55-70 g pro to meet her estimated nutrient needs. However res [resident] is on hospice so plan may be to taper down the TF [tube feeding], will await communication with hospice to clarify POC [plan of care] for res, otherwise with the new regimen that the res is on it is likely that she will experience wt. [weight] loss. Will continue to monitor wts and TF tolerance at this time, In a follow-up interview with the DON on 10/12/22 at 11:50 a.m. the DON stated Nursing staff in the facility failed to communicate to the Registered Dietitian (RD) to recalculate the caloric needs of 555744 Page 3 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 40. The DON further stated they needed to follow the Physician's order or clarify it if it is not making sense. The DON stated the nurse should have notified their RD of the enteral feeding order from hospice. Review of an undated facility policy titled, Enteral Nutrition, indicated, . Adequate nutritional support through enteral feeding will be provided to residents as ordered . The Dietitian, with input from the Physician and Nurse, will . Estimate calorie, protein, nutrient and fluid needs . Determine whether the resident's current intake is adequate to meet his or her nutritional needs . 2. Resident 27 was admitted to the facility in mid 2022 with diagnoses that included right heart failure. Review of Resident 27's Client Coordination Note Report from Resident 27's hospice agency, dated 9/27/22, indicated, . RECEIVED PHONE CALL FROM FACILITY NURSE, REPORTING PATIENT DEVELOPED OPEN BLISTER TO RIGHT PLANTER [SIC] OF HIS FOOT, REQUESTS FOR A RN [Registered Nurse] ASSESSMENT . WOUND LOCATION: RIGHT PLANTER [SIC] OF FOOT . SHAPE: IRREGULAR . TYPE: OPEN BLISTER . MEASUREMENTS:10CM X 9CM . WOUND BED: 100% RED . WOUND EDGES: IRREGULAR . Review of Resident 27's document titled, Order Details, dated 9/28/22, indicated an order for, .open blister to right foot plantar, cleanse with NSS [normal saline solution], pat dry, apply silver alginate [wound dressing] to open blister skin prep to intact blister, triad to surround redness, apply abd pad, wrap with kerlix ace wrap 3x a week, non weight bearing as tolerated right foot . every day shift every Mon, Wed, Fri for wound care, until resolved and as needed for wound care Review of Resident 27's care plan , date initiated 10/11/22, indicated, The resident has an actual impairment to skin integrity r/t [related to] open blister to right foot plantar interventions . Administer treatment as ordered by physician . Review of Resident 27's documents indicated a Weekly Skin Alteration Report with an effective date of 10/11/22. There was no other documentation of a Weekly Skin Alteration Report of Resident 27's wound on right foot. In an interview with the Director of Nursing (DON) on 10/12/22 at 11:30 a.m., the DON confirmed there was no wound measurement of the wound on Resident 27's right foot done between 9/27/22 and 10/11/22. The DON stated the expectation is for wound measurements to be done on a weekly basis. The DON further stated the measurements were not taken on 10/11/22 as Resident 27 was getting agitated. The DON confirmed the wound care plan was initiated on 10/11/22 for the wound identified on 9/27/22. The DON further stated she prefers new resident conditions to be care planned right away. In a follow-up interview with the Director of Nursing (DON) on 10/13/22 at 7:45 a.m., the DON stated they did not have a policy for doing weekly wound measurements, but it is triggered in their system for wound measurements to be done weekly. The DON also stated the expecation is for wound measurements to be done weekly. Review of a facility policy titled, Comprehensive Care Plans, revised 7/1/20, indicated, . It is the policy of this facility that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change by the licensed nurse . 555744 Page 4 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0684 Level of Harm - Minimal harm or potential for actual harm According to Wound Source, What Is Standard of Care in Wound Care?, dated May 31st 2022, indicated, Documentation of a wound assessment is a vital component of the standard of wound care. Your documentation should adhere to your facility's documentation guidelines. Accurate documentation contributes to improved patient safety, outcomes, and care quality .Photographs, graphs of healing times, automatic measurements, and written descriptions are commonly used to document wound care. Residents Affected - Few 555744 Page 5 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored properly when two opened eye medications and an opened inhaler were not labeled with an open date, for a census of 66. These failures had the potential for residents to receive expired medications with decreased effectiveness. Findings: Resident 2 was admitted in the facility in mid 2022 with diagnoses that included unspecified asthma (a lung condition which can make breathing difficult). Review of Resident 2's Order Summary Report, active orders as of 10/13/22, indicated an order for [brand name] Aerosol 160-4.5 MCG/ACT (Budesonide - Formoterol Fumarate) [inhaler, a medication used for the treatment of asthma] 2 puff inhale orally two times a day for asthma . During a concurrent observation and interview with Licensed Nurse 1 (LN 1) on 10/11/22 at 2:15 p.m., medication cart B contained an opened [brand name] inhaler for Resident 2 with no opened date. LN 1 confirmed the observation. Resident 54 was admitted to the facility in late 2022 with diagnoses that included chronic angle-closure glaucoma (a condition of increased pressure within the eyeball), right eye. Review of Resident 54's Order Summary Report, active orders as of 10/13/22, indicated an order for Latanoprost Solution 0.005% [a medication used to treat glaucoma] Instill 1 drop in right eye at bedtime for glaucoma . Resident 108 was admitted to the facility in late 2022 with diagnoses that included hypotension (low blood pressure). Review of Resident 108's Order Summary Report, active orders as of 10/13/22, indicated an order for, Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime for glaucoma . During a concurrent observation and interview with LN 2 on 10/11/22 at 2:30 p.m., medication cart B contained 2 opened latanoprost eye drops for Resident 54 and Resident 108 with no open dates. LN 2 confirmed the observation. In an interview with the Director of Nursing (DON) on 10/13/22 at 7:39 a.m., the DON stated eye drops and inhalers should be dated once opened. Review of a facility policy titled, STORAGE OF MEDICATION, dated 9/18, indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Review of a facility policy titled, Storage of Medications, effective date 7/1/20, indicated, . 555744 Page 6 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Review of a facility policy titled, Abridged List of Medications with Shortened Expiration Dates, current as of April 2021, indicated, Once certain products are opened and in use, they must be used within a specific timeframe to avoid reduced stability, sterility, and potentially reduced efficacy . These In-Use medications should be labeled such that the DATE OPENED is noted, clearly visible and securely attached to a part of the package to not be discarded. This date is to be referenced when auditing to clear medications prior to expiration Budesonide/Formoterol . Beyond Use Date (BUD) Notes . 3 months after removal from foil pouch . Latanoprost . 6 week (42 days) after opening or moving to room temperature . 555744 Page 7 of 8 555744 10/13/2022 Siena Skilled Nursing and Rehabilitation Center 11600 Education Street Auburn, CA 95603

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to maintain Resident 59's medical records in accordance with professional standards when there was no documentation Resident 59 was discharged from the facility. The facility must maintain medical records on each resident that are complete and accurately documented. This failure could interfere with the ability of staff to respond to the changing status, needs, and the after care of the resident. Findings: Review of Resident 59's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery. Resident 59's clinical record contained a form titled Discharge Orders indicating resident to be discharged on 9/13/22. Review of Resident 59's progress notes revealed no documentation that Resident 59 was discharged from the facility on 9/13/22. Review of the facility's policy Discharging the Resident, effective date 7/1/20 indicated, The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individual(s) who assisted in the discharge. 3. All assessment data obtained during the procedure, if applicable 5. The signature and title of the person recording the data. In an interview with the Director of Nursing (DON) on 10/11/22 at 1:47 p.m. she confirmed there was no documentation in Resident 59's progress notes that indicated the resident was discharged from the facility on 9/13/22. 555744 Page 8 of 8