Health inspection·April 15, 2022

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 interview and record review, the facility failed to ensure a care plan was developed for the use of a lymphedema compression pump (a device used to help move sluggish fluid out of the immune and circulatory system in the body) for one resident (Resident 62) of 19 sampled residents for a census of 89. This failure decreased the facility's potential to provide safe application and use of medical equipment for Resident 62. Findings: A review of Resident 62's clinical record indicated he was admitted in 2018 with diagnoses which included morbid obesity and peripheral autonomic neuropathy (occurs when the nerves that control involuntary bodily functions are damaged). A review of a hospital's history and physical, dated 10/9/18, indicated Resident 62 had chronic lower extremity edema (swelling) and chronic numbness on both legs up to the thighs. A review of a hospital progress note by the facility on 3/18/22, dated 3/15/22, indicated, .Lymphedema pump and compression garment orders .Apply [compression system] to bilateral lower legs .set to 20-30 mmHg [millimeter(s) of mercury, a unit of measurement of pressure], apply [orthopedic shoe] to bilateral feet. Must remove with lymphedema pump use .lymphedema pump can be used 1-2 times daily, remove compression garments. Remove urinal and place .undergarment. Position call light and machine within easy reach of [patient]. [Patient] instructed to discontinue if [has signs and symptoms] of [shortness of breath]. Please replace compression garments afterwards. There was no documented evidence a lymphedema compression pump care plan was developed for Resident 62. A review of the facility's nurses notes indicated staff applied the lymphedema compression pump to Resident 62 on the following dates: 3/30/22 at 10:53 a.m., 3/31/22 at 9:45 a.m., and 4/1/22 at 2:02 p.m. In an interview and concurrent record review on 4/14/22 at 11:49 a.m., the Licensed Nurse 2 (LN 2) confirmed the lymphedema compression pump was received by the facility and was applied to Resident 62. The LN 2 confirmed there was no care plan for the use of the lymphedema pump and acknowledged there should have been one. Page 1 of 10 555801 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview and concurrent record review on 4/15/22 at 11:31 a.m., the Regional Director of Clinical Services (RDCS) stated she expected the facility nurses to develop a lymphedema compression pump care plan. The RDCS confirmed there was no care plan developed for Resident 62's use of the lymphedema compression pump. A review of the facility's policy, Care Planning- Interdisciplinary Team, revised 1/11, indicated, Facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 555801 Page 2 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

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 effective and person-centered care was provided for one resident, (Resident 62) of 19 sampled residents, when the facility did not notify the physician Resident 62's medical device was broken and did not obtain an alternate intervention. Residents Affected - Few These failures increased Resident 62's risk for progression of diagnosis and deterioration of well-being. Findings: A review of Resident 62's clinical record indicated he was admitted in 2018 with diagnoses which included morbid obesity and peripheral autonomic neuropathy (occurs when the nerves that control involuntary bodily functions are damaged). A review of a hospital's history and physical, dated 10/9/18, indicated Resident 62 had chronic lower extremity edema (swelling) and chronic numbness on both legs up to the thighs. A review of Resident 62's Minimum Data Set (MDS, an assessment tool), dated 1/21/22, indicated he had no memory problems. A review of a hospital document titled, Medical Record .Wound Care/Treatment, dated 3/15/22, and faxed to the facility on 3/18/22, indicated Resident 62 had surgery to remove a tumor. The document also indicated, .Lymphedema pump and compression garment orders .Apply [compression system] to bilateral lower legs .lymphedema pump can be used 1-2 times daily .Facility will coordinate time when appropriate staff (at least 3 people) can be trained in its use with this [patient] to provide treatment twice daily. A review of a progress note, dated 4/4/22 at 3:00 p.m., indicated, [The Licensed Nurse 2 (LN 2)] went to place lymphedema pumps in patient this [morning], writer noticed that there was a section of the garment was missing/broken .[LN 2] reached out to [distribution company] .[LN] boxed garment up and placed a sticky note on it saying, 'For [mail carrier] pickup .' There was no documented evidence Resident 62's physician was notified the lymphedema pump was broken. There was no documented evidence licensed staff requested an alternative intervention while the pump was being fixed. During an observation and concurrent interview on 4/14/22 at 11:22 a.m., Resident 62 was in bed and stated he was not wearing the compression pump because it was broken. Resident 62 also stated he did not have a spare because the compression pump was expensive. Resident 62 stated the pump helps him get the excess fluid out of his body and was a very important piece of equipment. Resident 62 validated he did not use it for several days now because it was not yet fixed. Resident 62 stated he should be using the compression pump daily for his lymphedema. During an interview and concurrent record review on 4/14/22 at 11:49 a.m., the LN 2 validated Resident 62 had a lymphedema compression pump he was supposed to wear twice a day everyday. The LN 2 stated Resident 62 used it for about a week. The LN 2 stated she inspected the garment and found there was evidence of damage. The LN 2 confirmed the broken pump was put in a box and the facility was still waiting for the supplier to pick it up. The LN 2 validated there was no alternative intervention in place while the compression pump was being fixed. During an interview and concurrent record review on 4/15/22 at 11:31 a.m., the Regional Director of Clinical Services (RDCS) validated there was no alternative intervention in place while the pump 555801 Page 3 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was broken. The RCDS stated she expected licensed nurses to notify the physician whether the lymphedema was improving and obtain an alternative intervention while the compression pump was being fixed. A review of the facility's policy titled, Change in a Resident's Condition or Status revised 5/17, indicated, Facility shall promptly notify .his or her Attending Physician of changes in the resident medical .condition and/or status .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observation and gather relevant and pertinent information for the provider . The American Nurses Association (ANA)'s Nursing Scope and Standards of Practice, 3rd Ed, defined nursing as, Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals . 555801 Page 4 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error was less than 5 percent (%) for a census of 89, when two medications out of 30 opportunities were not administered as prescribed to Resident 284. Residents Affected - Few This failure resulted in a medication error rate of 6.67% for the facility. Findings: A review of an admission record indicated Resident 284 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder that causes blood sugar levels to be abnormally high) with chronic kidney disease, diabetic polyneuropathy (diabetes complication characterized by progressive death of nerve fibers), and diabetic retinopathy (diabetes complication that affects eyes). A review of Resident 284's prescription order, dated 4/7/22, indicated, glipizide [a medication that helps control blood sugar levels] tablet .10 mg [milligrams, a unit of measure] .amt [amount] 2 tablets; oral [by mouth] twice a day .[7 a.m.] and [4 p.m.] For DM, 'give no more than 30 minutes before the meal'. A review of Resident 284's prescription order, dated 4/7/22, indicated, [regular] .insulin [a short-acting insulin that decreases blood sugar levels within 30 minutes] .amt: Per Sliding Scale .before meals and at bedtime .[7:30 a.m., 11:30 a.m., 5 p.m., 8 p.m.] .for DM. A review of Resident 284's DM care plan, dated 4/7/22, indicated, .at risk for ill effects such as .hyperglycemia [high blood sugar] .related to: DM. The care plan also indicated, blood sugar [to be] check [ed] as ordered [and to administer] medication as ordered. A review of the facility's meal service schedule, undated, for station II (two) indicated breakfast was served between 7:10 a.m. and 7:20 a.m. On 4/13/22 the following concurrent observations and interviews were conducted with LN 1: -At 8:14 a.m., LN 1 checked Resident 284's blood sugar level and the LN 1 stated it was 211; -At 8:19 a.m., LN 1 administered two tablets of glipizide, 10 mg each tablet, to Resident 284; and, -At 8:30 a.m., LN 1 administered four units of short-acting insulin into Resident 284's abdomen. During an interview on 4/13/22 at 8:35 a.m., the LN 1 stated, Yes, [Resident 284] ate his breakfast already. I'm late [to check his blood sugar and administer his medications]. During an interview on 4/13/22 at 2:27 p.m., the LN 1 stated, glipizide [was] given at 8:19 [a.m.]. During an interview on 4/15/22 at 12:27 p.m., the Director of Nursing (DON) stated, .the best practice is [for blood sugar levels] to be [checked] before meals .glipizide per pharmacy, must be given no more than 30 minutes before meals .[licensed nurses] can't [give short-acting insulin] before 555801 Page 5 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0759 meals .It may cause hypoglycemia [a condition in which the blood sugar level is lower than normal]. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy and procedure (P&P) titled, Medication Administration Schedule, revised April 2007, indicated, Medications are administered according to the following routine schedule .ac (before meals at) 7 a.m.; 11 a.m.; and 5 p.m .Insulin (daily) .7 a.m Insulin (twice daily) .7 a.m. and 5 p.m. Residents Affected - Few A review of the facility's P&P titled, Administering Medications revised 3/22/18, indicated, Medications must be administered in accordance with the orders, including any required time frame .must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 555801 Page 6 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0760 Ensure that residents are free from significant medication errors. 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 one resident (Resident 284) of a census of 89, was free from significant medication errors when insulin was administered late. Residents Affected - Few This failure increased Resident 284's risk of complications of diabetes (a chronic (long-lasting health condition that affects how your body turns food into energy). Findings: A review of an admission record indicated Resident 284 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM, a disorder that causes blood sugar levels to be abnormally high) with chronic kidney disease, diabetic polyneuropathy (diabetes complication characterized by progressive death of nerve fibers), and diabetic retinopathy (diabetes complication that affects eyes). A review of Resident 284's prescription order, dated 4/7/22, indicated, glipizide [a medication that helps control blood sugar levels] tablet .10 mg [milligrams, a unit of measure] .amt [amount] 2 tablets; oral [by mouth] twice a day .[7 a.m.] and [4 p.m.] For DM, 'give no more than 30 minutes before the meal'. A review of Resident 284's prescription order, dated 4/7/22, indicated, [regular] .insulin [a short-acting insulin that decreases blood sugar levels within 30 minutes] .amt: Per Sliding Scale .before meals and at bedtime .[7:30 a.m., 11:30 a.m., 5 p.m., 8 p.m.] .for DM. A review of Resident 284's DM care plan, dated 4/7/22, indicated, .at risk for ill effects such as .hyperglycemia [high blood sugar] .related to: DM. The care plan also indicated, blood sugar [to be] check [ed] as ordered [and to administer] medication as ordered. A review of the facility's meal service schedule, undated, for Resident 284's nurse's station indicated breakfast was served between 7:10 a.m. and 7:20 a.m. On 4/13/22 the following observations and concurrent interviews were conducted with LN 1: -At 8:14 a.m., the LN 1 checked Resident 284's blood sugar level and the LN 1 stated it was 211; -At 8:19 a.m., the LN 1 administered two tablets of glipizide, 10 mg each tablet, to Resident 284; and, -At 8:30 a.m., the LN 1 administered four units of short-acting insulin into Resident 284's abdomen. During an interview on 4/13/22 at 8:35 a.m., the LN 1 stated, Yes, [Resident 284] ate his breakfast already. I'm late [to check his blood sugar and administer his medications]. During an interview on 4/13/22 at 2:27 p.m., the LN 1 stated, glipizide [was] given at 8:19 [a.m.]. During an interview on 4/15/22 at 12:27 p.m., the Director of Nursing (DON) stated, .the best 555801 Page 7 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few practice is [for blood sugar levels] to be [checked] before meals .glipizide per pharmacy, must be given no more than 30 minutes before meals .[licensed nurses] can't [give short-acting insulin] before meals .It may cause hypoglycemia [a possible life threatening condition in which the blood sugar level is lower than normal]. A review of the facility's policy and procedure (P&P) titled, Medication Administration Schedule, revised April 2007, indicated, Medications are administered according to the following routine schedule .ac (before meals at) 7 a.m.; 11 a.m.; and 5 p.m .Insulin (daily) .7 a.m Insulin (twice daily) .7 a.m. and 5 p.m. A review of the facility's P&P titled, Administering Medications revised 3/22/18, indicated, Medications must be administered in accordance with the orders, including any required time frame .unless otherwise specified (for example, before and after meal orders) . A review of Diabetic Medicine's article titled Optimal prandial timing of bolus insulin in diabetes management: a review, dated 10/12/17, indicated, .In patients treated with multiple daily injections of insulin, both the dose and timing of meal-related rapid-acting insulin are key factors .studies of rapid-acting insulin .suggest that administering these 15-20 min before food would provide optimal postprandial [after meal] glucose control .Importantly, there was also a greater risk of postprandial hypoglycemia when patients took rapid-acting analogues [insulin] after eating compared with before eating A review of the Center for Disease Control and Prevention, reviewed 3/9/22, indicated, .diabetes health complications include heart disease, chronic kidney disease, nerve damage, and other problems with feet, oral health, vision, hearing, and mental health . A review of the Institute for Safe Medication Practices (ISMP) article titled .2007 Survey on HIGH-ALERT Medications: Differences Between Nursing and Pharmacy Perspectives Still Prevalent, dated 5/17/07, indicated 85% of quality/risk/safety managers considered insulin administered subcutaneously (in a layer of fat under the skin) was a high-alert medication. 555801 Page 8 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and facility record review, the facility failed to follow safe food preparation and handling practices when: Residents Affected - Some 1. The facility's ice machine was not maintained in a sanitary condition; 2. Resident 27's food item was unlabeled and stored in the Nursing Station nourishment refrigerator; and 3. The sanitizing procedure for the dishwasher was not followed. These failures had the potential to cause food borne illnesses among residents for a census of 89. Findings: 1. On 4/13/22 at 9:58 a.m. an inspection of the facility's ice machine was conducted at Nursing Station 2 accompanied by the Maintenance Supervisor (MS). The MS confirmed there was only one ice machine for the entire facility. The MS stated he usually cleans the ice machine once a month and uses a sanitizer for the machine. The MS was asked to provide the sanitizer used to clean and sanitize the ice machine. A review of the sanitizer was conducted on 4/13/22 with the MS at 10:05 a.m. The label on the sanitizer bottle indicated the chemicals used were mainly, .Dimethyl Benzyl Ammonium Chloride .Dimethyl Ammonium Chloride .Dioethyl Ammonium Chloride . A review of the instructional manual for the ice machine, revised 2/27/09, indicated, .To prevent injury to individuals and damage to the icemaker, do not use ammonia type cleaners .Sanitizing Procedure- Following Cleaning Procedure .Dilute a 5.25% sodium hypochlorite solution (chlorine bleach) with warm water. In an interview on 4/13/22 at 10:09 a.m., the MS confirmed the sanitizer he was using on the ice machine was ammonia based. The MS stated he must use a chlorine type cleaner and sanitizer as indicated in the instruction manual. 2. During an observation of the Nursing Station 2 unit refrigerator on 4/13/22 at 10 a.m. with the Licensed Nurse 3 (LN 3), a plastic container with a brownish, white colored cupcake was found in the refrigerator. The container was labeled with Resident 27's name and room number. The LN 3 stated resident food stored in the refrigerator must have a name, time, and date the food was stored in the refrigerator. The LN 3 confirmed the plastic food container which contained the cupcake did not have a time and date when it was stored in the refrigerator. The LN 3 further stated food stored in the refrigerator is usually thrown out after 2 days. The LN 3 stated she cannot confirm how long the food item had been stored in the refrigerator nor when the food item should be tossed out. A review of the facility census, dated 4/13/22, indicated Resident 27 was discharged from the facility on 3/1/22. A review of the facility's policy and procedure titled Food for Residents From Outside Sources, dated 2018, indicated, .Prepared foods, beverages, or perishable food that require refrigeration can be stored in the facility kitchen, nursing station's refrigerator .If opened, the food must be sealed, 555801 Page 9 of 10 555801 04/15/2022 Pine Creek Care Center 1139 Cirby Way Roseville, CA 95661

F 0812 dated to the date opened and disposed of in 2 days after opening. Level of Harm - Minimal harm or potential for actual harm 3. An observation and concurrent interview with the Registered Dietitian (RD), the Food Service Manager, and the kitchen Dishwasher Technician (DT) was conducted in the facility kitchen. The DT was unable to demonstrate how to determine if the sanitizer was the correct concentration by using a test strip. The DT was unable to state what chemical was used to sanitize the dishes. Residents Affected - Some During an interview on 4/14/22 at 10:15 a.m., the RD stated the DT was unable to demonstrate the chlorine solution test because the DT was nervous and flustered. A review of the specification sheet from the manufacturer of the test strips, dated 7/6/18, indicated, .Directions .dip the strip into the chlorine sanitizing solution, blot with paper towel, and then instantly compare the resulting color with the enclosed color chart which matches chlorine concentrations of 10-50-100-200 ppm [parts per million, a unit of measure]. 555801 Page 10 of 10