Every finding on record at Arbol Healthcare Center of Santa Rosa

Based on interview and record review, the facility placed the life of one of three sampled residents (Resident 1) in danger when the facility discharged her from the facility when her insurance coverage ended. The facility did so fully aware Resident 1's family could not provide care at home, and without an appropriate discharge plan, transfer documentation, or follow-up aftercare. In addition, the facility physician discharge orders for Physical therapy (PT, the practice of improving mobility and flexibility through a variety of exercises and other treatments), Occupational Therapy (OT, a therapy that uses everyday life activities to promote health, well-being, and the ability to participate in important activities) and Registered Nursing Services, dated 11/28/25, were not followed.As a result, Resident 1 was immediately hospitalized after discharge from the facility, with a post-surgical abdominal wound dehiscence (when a surgical incision splits open again requiring prompt medical attention) requiring immediate surgery. A review of Resident 1's facility admission Record (Facility demographic), indicated Resident 1 was admitted to the facility on [DATE] with multiple diagnoses which included disruption or dehiscence of closure of internal operation (surgical) wound of abdominal wall, end stage renal disease (when kidneys lose almost all function, requiring dialysis or transplant), and cognitive communication deficit (a difficulty in expressing or understanding messages due to impaired thinking skills like attention, memory, problem-solving, or organization).A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 11/28/25, indicated Resident 1had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 which indicated Resident 1 was cognitively intact (A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS also indicated Resident 1 used a wheelchair, required substantial/maximum assistance for toileting, showering, dressing, bed mobility, and transfers. In addition, the MDS indicated Resident 1 received hemodialysis (a life-sustaining treatment that acts as an artificial kidney, filtering waste, toxins, and extra fluid from the blood when kidneys fail), speech therapy, occupational therapy, and physical therapy while in the facility. The MDS also indicated Resident 1 had a recent surgery requiring active Skilled Nursing Facility (SNF) care.A review of Resident 1's facility document titled, Care Plan Report, initiated on 11/18/25 indicated interventions for safe discharge included, make arrangements with required community resources to support independence post-discharge for [Resident 1's] preferred home care, PT, OT, MD [Medical Doctor], Wound Nurse.make arrangements with required community resources to support independence post-discharge.A review of Resident 1's facility document titled, Order Summary Report, dated 12/04/25, indicated Resident 1 was prescribed wound Vacuum-Assisted Closure (VAC therapy- a special foam dressing, tubing, and a portable pump to create gentle suction on a wound, removing fluid, reducing swelling, and promoting the growth of new tissue for faster healing) care and to, apply black foam on top of wound bed and cover with vac tape. Set wound vac to 125 mmHg [meters of mercury, a unit used to measure pressure] continuous pressure.A review of Resident 1's wound care note titled, SNF Wound Care @ [at] [Facility name], dated 11/24/25, indicated Resident 1's abdominal wound measured 14.0 cm (centimeters-a unit of measure) x 10.0 cm x UTD [unmeasurable] after debridement (a medical procedure to remove dead, damaged, or infected tissue), with light serosanguineous drainage (a normal, watery, pale pink or reddish fluid from a healing wound, a mix of clear serum and a small amount of blood, indicating healthy healing).A review of Resident 1's facility Progress Notes, dated 11/25/25, indicated Social Services Director (SSD) presented Resident 1 and spouse (FM) with a Notice of Medicare Non-Coverage (NOMNC-a form Medicare providers must give beneficiaries when their Medicare-covered services are ending, informing them of their right to appeal the decision) on 11/27/25 for impending discharge on [DATE]. This note indicated when FM received this form, he stated, if she [Resident 1] discharges on 11/28/25 I will be bringing her straight back to the hospital and that's that.A review of Resident 1's facility document titled, Notice of Transfer or Discharge, dated 11/28/25, indicated Resident 1 was notified on 11/28/25 about impending discharge home on that same date. According to this document, the facility determined the reason for discharge was, The transfer or discharge is appropriate because your health has improved sufficiently so that you no longer require services provided by this facility. The form was signed by the SSD.A review of Resident 1's facility Progress Notes, dated 11/28/25, indicated SSD documented, this writer was approached by residents' [Resident 1's] spouse, resident and resident's spouse requesting transportation to be arranged for discharge, this writer arranged transportation for resident to discharge to home.During a phone interview on 12/04/25 at 2 p.m., FM stated the facility attempted to send Resident 1 home on [DATE], but he called an ambulance to take Resident 1 directly to [General Acute Care Hospital-GACH] instead because they lived in a recreational vehicle (RV). FM explained the RV had stairs and the doors/insides could not safely accommodate Resident 1's wheelchair. FM stated Resident 1 was initially informed of discharge because Medicare insurance coverage was ending on 11/20/25 but was granted a few more days after an appeal. FM stated he also appealed the next discharge date of 11/27/25 (Medicare coverage was ending on that date), however it was denied by the Medicare insurance company. FM stated the facility did not inform him of an opportunity of a second level appeal (when a Qualified Independent Contractor (QIC), contracted by CMS (Centers for Medicare and Medicaid Services) conducts a reconsideration in Medicare eligibility and coverage) for Resident 1's continued skilled nursing care after 11/27/25. FM also stated the facility did not try to find any alternatives for Resident 1's aftercare or offer any alternative means of staying in the facility, other than private pay options which FM stated he could not afford. FM stated he informed the facility of these difficulties each time the facility attempted to discharge Resident 1, including FM's inability to get after-care for Resident 1, and that he did not have the money to pay for Resident 1's continued stay at the facility without Medicare payments. At no time prior to Resident 1 or FM receiving the facility Notice of Transfer of Discharge on 11/28/25 had Resident 1 accumulated any unpaid facility charges.During a concurrent interview and record review on 12/04/25 at 2:31 p.m. with SSD, he stated Resident 1's Medicare insurance coverage would initially end on11/20/25, but an appeal for continued care and coverage was granted. A review of Resident 1's NOMNC, signed by Resident 1 on 11/25/25, indicated a new Medicare insurance end-date of 11/27/25, for which another appeal was filed for continued skilled nursing services. A review of a document titled, Beneficiary and Family Centered Cared Quality Improvement Organizations (BFCC-QIO-designed to help Medicare beneficiaries who have a complaint about clinical quality or want to appeal a healthcare provider's decision to discharge them from the hospital or discontinue other types of services) Determination Letter, from [Insurance company], dated 11/27/25, indicated Resident 1's last day of paid skilled nursing services would be 11/27/25. The denial reason documented indicated Resident 1 had not shown any further progress with therapy, and no skilled nursing services were needed to maintain function or prevent decline. The SSD stated a second level appeal would have allowed Resident 1 to remain in the facility during the second level appeal process, but he, may have missed offering Resident 1 that option. SSD stated Resident 1 would have benefited from additional skilled nursing services, but FM did not or could not afford to pay for this care on his own. SSD stated he did not arrange aftercare services or referrals for Resident 1, because FM told SDD that Resident 1 would be taken directly to an acute care hospital after discharge instead of home.A review of Resident 1's facility Prescriber Order Note, dated 11/28/25, indicated the facility physician (PHY) documented the following order, May D/C [discharge] home with meds [medications] PT/OT/RN on 11/28/25.A review of Resident 1's facility Progress Notes, dated 11/28/25, indicated [Resident 1] left the facility at 1230 [12:30 p.m.] via comfort care transport accompanied by husband.During an interview on 12/04/25 at 12:30 p.m., with PHY, he stated because of the difficulties surrounding Resident 1's discharge environment and the issues regarding Resident 1's after care, he considered it was a safe decision to send Resident 1 back to [GACH] rather than home. Yet, his discharge note (above) dated 11/28/25 indicated, May D/C home with meds.A review of a facility document for Resident 1 titled, Discharge Instruction, dated 11/28/25, indicated no appointments were listed as scheduled with Resident 1's primary care physician or in-home care services. Sections of the discharge instructions regarding special training/instructions for dressing changes, wounds, current treatments/therapies, and special observations were left blank. The skin condition section indicated Wound vac is disconnected on discharge and MD is aware. Resident 1 or FM's signature was not on this discharge document.A review of Resident 1's General Acute Care Hospital (GACH) document titled, Acute Care Surgery Consultation, dated 11/28/25, indicated Resident 1, had a wound VAC in place which is not connected to anything, this was removed and there is an underlying open wound about 15 x 10 cm with pink granulation [the new, healthy, pinkish-red tissue that fills a wound during healing] tissue. This document was from the GACH that received Resident 1 after discharge from the nursing facility.A review of Resident 1's GACH document titled, Hospitalist History and Physical, dated 11/29/25, indicated Resident 1 was admitted to [GACH] on 11/28/25. This document indicated, .Patient [Resident 1] had bowel resection [surgery to remove part of the small or large intestine] on 10/20/2025 with skin dehiscence and wound VAC was in place. She [Resident 1] does not remember when it started malfunctioning. She says that her wound VAC was replaced earlier today. Surgery was consulted apparently wound VAC was not connected.During an interview on 12/04/25 at 1:20 p.m., with the facility Administrator (ADM) and Operations Manager (OPM), ADM stated the reason Resident 1 was discharged from the facility was because Medicare insurance was ending. ADM and OPM both stated it would have been clinically appropriate for Resident 1 to remain in the facility had Medicare insurance coverage continued.During an interview on 12/04/25 at 1:21 p.m. with the ADM and the OPM, the ADM stated Resident 1's wound vacuum was removed just prior to discharge on [DATE] at 12:30 p.m., because it was a facility-owned medical appliance, and a new one should have been ordered for replacement by the SSD as part of discharge planning. When it was discussed that the SSD did not make any post-discharge arrangements for Resident 1, OPM stated, that was a misstep on [SSD's] part.During a phone interview on 12/10/25 at 3 p.m., with the facility's Director of Nursing (DON), the DON stated discharge planning was crucial for residents because it prevented harm. The DON stated the facility should have ensured Resident 1 was discharged to a safe environment, and the facility was responsible for making referrals or appointments for ongoing medical/nursing care for discharged Residents. The DON stated in cases where a Resident was transferred to another facility or a GACH, the facility should send thorough documentation and make a verbal nurse-to-nurse report from the facility to the receiving hospital to communicate routine and special instructions. The DON stated the SSD was primarily responsible for ensuring discharges were made appropriately and completely. When asked why transfer paperwork was not sent to [GACH] for Resident 1, the DON replied, everyone thought that [Resident 1] was discharging home, yet FM had clearly communicated to SSD on multiple occasions that Resident 1 would go directly to a GACH from facility upon discharge.During an interview on 12/11/25 at 1:50 p.m. with a GACH (to which Resident 1 was sent on 11/28/25) Wound Care Nurse (WCN), the WCN stated he had cared for and had personal knowledge of Resident 1's wound care hospital course. The WCN stated Resident 1 came to the GACH on 11/28/25 with a wound vac dressing which was not hooked up to suction, and per Resident 1's statement, was malfunctioning prior to this. The WCN stated surgery was performed on 11/28/25 at 9:20 p.m. to remove Resident 1's 3M foam dressing (key component for VAC Therapy to promote healing by removing fluid, reducing swelling, and encouraging tissue growth in various wounds) that should never have been left unattached to suction for more than two hours. The WCN stated because many hours had passed between when Resident 1 left the facility and when the dressing was surgically removed, Resident 1 was at risk for harm from delayed wound healing and infection. The WCN stated an attempt to restart wound Vac therapy on 12/8/25 was unsuccessful, thus another possibly slower healing type of wound care was immediately initiated for Resident 1.A review of the facility's current Policy and Procedure (P & P) titled, Transfer and Discharge Documentation, dated 1/2019, indicated, When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.Each resident will be permitted to remain in the facility, and not be transferred or discharged unless b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility. e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at this facility.A review of the facility's current P & P titled, Transfer or Discharge Notice, dated 2001, indicated, In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident.A review of a document provided by the facility, titled, Patient guide for 3M(tm) V.A.C.(R) Therapy with 3M(tm) V.A.C.(R) Peel and Place Dressing, copyrighted 2024, indicated Keep the therapy unit on. If off for more than two hours, the dressing will need to be changed.

Based on observation, interview, and record review, the facility failed to implement and maintain a safe and sanitary environment with an effective infection prevention and control program for two of 13 sampled resident's (Resident 33 and Resident 4) when: 1.Certified Nursing Assistant (CNA) 1 entered a coronavirus (COVID-19- a contagious serious respiratory infection transmitted from person to person) isolation room with a surgical mask.2. Enhanced Barrier Precautions (EBP, an infection control strategy in nursing homes that expands the use of Personal Protective Equipment (PPE), specifically gowns and gloves, for high-contact care activities to prevent the spread of multidrug-resistant organisms), was not followed for one of 13 sampled residents (Resident 4).These failures had the potential to place residents and staff at increased risk for infections. Findings: 1.During an observation on 9/16/25 at 3:28 P.M. near room [ROOM NUMBER], a red sign was posted which read Stop Special droplet/contact precautions. A three-compartment cart was located next to the door which contained Personal Protective Equipment (PPE-protective clothing to prevent infection). The room door was open and CNA 1 walked out of the room with a surgical face mask. During an interview on 9/16/25 at 3:29 P.M. with CNA 1, CNA 1 stated she was in the room giving Resident 33 a bath. CNA 1 stated she was wearing a surgical mask because wearing an N95 (mask approved to filter airborne particles) made it hard to breathe and fogged up her glasses. CNA 1 stated she was supposed to wear an N95 when in a droplet isolation room. During an interview on 9/17/2025 at 9:48 A.M. with Infection Preventionist (IP), IP stated the purpose of wearing the N95 was to prevent transmission of infection and source control. IP stated, Resident 33 was on isolation for COVID-19 and that staff should be wearing an N95 when entering the room. During a concurrent interview and record review on 9/18/25 at 11:18 A.M. with the Director of Nursing (DON), the facility policy and procedure titled COVID-19 Isolation Quarantine PPE Requirement dated 8/14/25 was reviewed. The policy indicated .To prevent the spread of COVID 19 and to protect Residents and Staff affected by the infectious disease. Staff need to wear .N95 respirator .when caring for symptomatic or confirmed COVID-19 positive residents on isolation . The DON stated staff should wear N95 in COVID-19 isolation for protection against the virus. 2. During a review of Resident 4's admission Record, dated 9/17/2025, the admission record indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS, a chronic, autoimmune disease that affects the brain and spinal cord) and had a gastrostomy tube (a surgical procedure that creates an opening in the abdomen into the stomach). During an observation on 9/17/2025 at 8:49 a.m. outside Resident 4's room, an EBP poster was posted next to Resident 4's name. The EBP poster indicated staff must wear gloves and gown for high-contact resident care activities including Device care or use, feeding tube (flexible tube inserted directly into the stomach to deliver food). During a concurrent observation and interview on 9/17/2025 at 8:51 a.m. with Registered Nurse (RN) 3 in Resident 4's room, RN 3 was observed wearing gloves and disconnecting Resident 4's feeding tube from Resident 4's stomach. RN 3 stated, I just forgot to put the gown on and did not pay attention. RN 3 further stated, I should have worn it because Resident 4 is on EBP precautions. RN 3 stated, EBP precautions need to be followed to reduce risk of contamination to the residents. During an interview on 9/17/2025 at 8:55 a.m. with the Infection Preventionist (IP), IP stated staff must wear gowns and gloves when disconnecting Resident 4's feeding tube because of Resident 4's EBP precautions. IP further stated, not following the EBP precautions can spread the infection to other residents. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated 6/20/2024, the P&P indicated, Facility staff shall perform hand hygiene and will don gown and gloves before performing the following high-contact resident care activities: Device care or use, feeding tube.

Based on observation, interview, and record review, the facility failed to maintain professional standards when oxygen was administered to one of 13 sampled residents (Resident 35), without a physician's order.This failure had the potential to cause harm to the residents. Findings:During a review of Resident 35's admission Record, dated 9/16/2025, the admission record indicated, Resident 35 was admitted to the facility on [DATE] with diagnoses of emphysema (a disease where the air sacs in the lungs are damaged), respiratory failure with hypoxia (a condition where the lungs fail to provide enough oxygen), and dependence on supplemental oxygen (the need for supplemental oxygen therapy to maintain adequate oxygen levels in the body). During an observation on 9/16/2025 at 1:57 p.m. in Resident 35's room, Resident 35 was observed lying in bed while receiving four liters per minute continuous supplemental oxygen through nasal cannula (a thin, two-pronged plastic tube device that delivers supplemental oxygen from the oxygen tank to the nostrils).During a review of Resident 35's Order Summary Report, dated 9/16/2025, the order summary report indicated there was no physician order for oxygen for Resident 35.During an interview on 9/17/2025 at 2:00 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN stated there was no oxygen order from the physician. MDSN stated this must have been overlooked.During an interview on 9/18/2025 at 11:01 a.m. with the Medical Doctor (MD 1), MD 1 stated oxygen is considered a medication and oxygen administration must have a physician's order. MD 1 stated that oxygen administration without physician's order can harm residents with hypoxia (not enough oxygen in the body) or oxygen toxicity (too much oxygen in the body).During an interview on 9/18/2025 at 11:45 a.m. with the Director of Nursing (DON), the DON stated, I forgot to put the order in, I was busy with admission and did not enter her oxygen order. The DON added that the expectation was for all medications, including oxygen, to have a physician order, or it could harm the residents. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated, Guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure .

Based on observation, interview, and record review, the facility failed to provide care that respected resident dignity for one out of 13 sampled residents (Resident 34) when: 1. Staff did not close Resident 34's privacy curtain and door when performing a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) and influenza (a respiratory infection caused by influenza virus) swab on Resident 34.2. Staff did not knock on Resident 34's room prior to entering. These failures had the potential for improper care to the residents. Findings:1. During a review of Resident 34's admission RECORD (AR), dated 9/16/2025, the admission record indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a condition where blood flow to the brain is interrupted), apraxia (a disorder that affects speech) and aphasia (a disorder that affects the ability to understand language). During a concurrent observation and interview on 9/15/2025 at 4:03 p.m. with the Registered Nurse (RN) 1, outside of Resident 34's room, Resident 34 was lying in the bed, and was visible from the hallway. Resident 34's privacy curtain was not closed, and the door was wide open. RN 1 was observed swabbing Resident 34's nostrils. RN 1 stated the nostril swabs were to obtain COVID-19 and influenza samples.During a concurrent observation and interview on 9/15/2025 at 4:08 p.m. with Resident 34, in Resident 34's room, Resident 34 had difficulty forming words and was unable to move her right side of the body. Resident 34 was asked if it bothered her when RN 1 swabbed her nostrils without closing her privacy curtains, and Resident 34 nodded her head up & down with facial grimacing (a distorted facial expression that typically conveys pain or discomfort).During an interview on 9/15/2025 at 4:12 p.m. with RN 1, RN 1 stated I am only on call. I'm off shift right now, and walked away from this surveyor.During an interview on 9/18/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated all staff must close residents' privacy curtain when performing nostrils swab testing to protect their privacy and maintain their dignity. During a review of facility's policy and procedure (P&P) titled, Quality of Life - Dignity, [undated], the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .2. During a review of Resident 34's admission RECORD, dated 9/16/2025, the admission record indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a condition where blood flow to the brain is interrupted, causing damage to brain tissue), apraxia (a disorder that affects speech) and aphasia (a disorder that affects the ability to understand language). During an observation on 9/15/2025 at 4:08 p.m. in Resident 34's room, the Registered Nurse (RN 1) entered Resident 34's room without knocking, no communication with Resident 34, picked up her things and left the room.During an interview on 9/15/2025 at 4:12 p.m. with RN 1, RN 1 stated I am only on call. I'm off shift right now, and walked away from this surveyor.During an interview on 9/18/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated all staff must knock and ask permission before entering any of the residents' rooms. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, [undated], the P&P inidicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality.Residents' private space and property shall be respected at all times.Staff will knock and request permission before entering residents' rooms .

Based on interview and record review, the facility failed to ensure a physician obtained informed consents (a process in which residents are given important information of the possible risk and benefits of the use of psychotropic medications-drug affecting mental state) for one of thirteen sampled residents (Resident 38) when Resident 38 received Trazodone HCl (an antidepressant medication) and Escitalopram Oxalate (antidepressant medication) without an informed consent.This failure had the potential in Resident 38 receiving psychotropic medications without being fully informed of the risk and benefits of the medication being administered.Findings:During a concurrent interview and record review on 9/17/25 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 38's physician orders were reviewed. The orders included Trazadone and Escitalopram Oxalate. LVN 1 stated there was no consent obtained for both medications and that it was the licensed nurse's responsibility to ensure the consent was obtained.During an interview on 9/17/2025 at 2:17 p.m. with Minimum Data Set Nurse (MDSN), MDSN stated a consent for Escitalopram and Oxalate Trazodone HCl needed to be obtained.During a concurrent interview and record review on 9/18/25 at 11:20 a.m. with the Director of Nursing (DON) the facility policy and procedure titled Informed Consent Policy dated 01/2024 was reviewed. The policy indicated .It is the policy of this Facility to involve residents in their care decisions by facilitating information and obtaining consent for the use of psychotropic drugs, physical restraints and medical devices which may lead to the inability to regain use of a body function after prolonged use . The DON stated it was the nurse's responsibility to ensure the informed consent was signed. The DON stated the purpose of the consent was to ensure the resident or family know the risk and benefits.

Based on interview and record review, the facility failed to complete a Physician Orders for Life Sustaining Treatment (POLST- is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) for one of thirteen sampled residents (Residents 33).This deficient practice had the potential for Resident 33 to receive unnecessary care and/or treatment services against the resident's wishes.Findings:During an interview on 9/15/25 at 3:38 P.M. with Resident 33, Resident 33 stated that she would like a copy of the POLST but it was not given. During a concurrent interview and record Review on 9/17/25 at 11:28 A.M. with Licensed Vocational Nurse (LVN) 1, Resident 33's POLST was reviewed. LVN 1 stated the POLST was in the chart but was not completed. LVN 1 stated it was the nurse's responsibility to ensure that the POLST was completed. LVN 1 stated on 9/14/25, the progress note indicated a follow up would be done but no follow up was done. During a concurrent interview and record review on 9/18/25 at 11:17 A.M. with the Director of Nursing (DON) the facility policy and procedure titled Advanced Directive dated 12/2016 was reviewed. The policy indicated .Upon admission, the resident will be provided with written information concerning the right to refuse medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . The DON stated the physician goes over the POLST with the resident and it was the nurse's responsibility to ensure it was completed.

Based on interview and record review, the facility failed to provide a written Notice of Medicare Provided Non-Coverage (NOMNC-a notice that informs the beneficiary about the impending end of coverage and their right to appeal the decision) for one of thirteen sampled residents (Resident 42) when Medicare coverage was terminated. This deficient practice resulted in not protecting Resident 42's right to appeal the termination of Medicare Part A and possibly denying Resident 42's needed services. Findings:During a review of Resident 42's Minimum Data Set (MDS- a report that helps the healthcare team plan the best treatment and services for a resident in a skilled nursing facility), the MDS indicated that Resident 42 was admitted to the facility on [DATE] with diagnoses that included sepsis (a severe life-threatening reaction to infection) and cancer. During a concurrent interview and record review on 9/16/2025 at 2:00 p.m. with Operations Manager (OM), OM reviewed the facility document titled, Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review which indicated Resident 42's Medicare Part A Skilled Services Episode start date was 9/13/2024 and the last covered day of Medicare Part A Service was on 3/3/2025. OM stated that a NOMNC was not provided to Resident 42 because the previous ownership [had] miscalculated days at SOC (start of care) on 11/23/2024 as previous days used [at] 49.when [it] should have been 47. OM indicated that because of the miscalculation of days previously used, the facility failed to ensure that Resident 42 received the required NOMNC timely. During a review of the facility's policy and procedure (P&P) titled, Medicare Denial Process Beneficiary Notices dated 11/27/2023, the P&P indicated, Medicare beneficiaries will be properly notified in accordance with the most current Centers for Medicare and Medicaid Services (CMS) Beneficiary Notice guidelines when it is determined that they do not meet the requirements for covered skilled services under the Medicare program. The use of notification form including the timing and instructions will be based on CMS guidelines on CMS/Medicare Beneficiary Notice Initiative (BNI- a program that makes skilled nursing facilities tell residents ahead of time when Medicare will stop paying for their care) .and will be used by the facility upon; a minimum of 2 days prior to the last Medicare Part A covered day. This includes the denial date, last covered day and first day of non-coverage, and the appropriate type of denial letter to be initiated based on the reason for denial.

Based on interview, and record review, the facility failed to maintain a safe and comfortable environment for three of 13 sampled residents (Resident 6, Resident 8 and Resident 18) when:1. Resident 6's inventory sheet was not updated and was inaccurately completed. This failure had the potential to result in Resident 16's belongings not being documented in the event of an alleged loss or theft.2. Fire alarm test was conducted without notification to Resident 8 and 18. This failure resulted in Resident 8 and 18 feeling startled.Findings:1.During an interview on 9/15/25 at 4:40 p.m. with Family (FM), FM stated that the facility had misplaced her dad's hearing aids and that she had to purchase a new set. FM stated she was unaware of the inventory log.During a concurrent interview and record review on 9/17/25 at 9:24 a.m. with Social Service Director (SSD), Resident 6's Inventory of Personal Effects (IPE) dated 8/27/25 was reviewed. The IPE indicated, one left hearing aid. SSD stated the inventory was not documented accurately since he had two hearing aids. SSD stated on 9/6/25 the daughter had purchased new pair of hearing aids which was not inventoried.During a concurrent interview and record review on 9/18/25 at 11:32 a.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Resident's Personal Belongings-Personal Property dated 6/13/25 was reviewed. The P&P indicated .The resident's personal belongings and clothing shall be inventoried and documented upon admission and as needed as changes are made . The DON stated that it was the nurses and SSD responsibility to inventory personal belongings, to ensure safety and reimburse the resident in the event it gets lost or stolen.2.During an interview on 9/16/25 at 2:36 p.m. with Resident 18, Resident 18 stated a week ago the facility conducted a fire alarm test without informing her. Resident 18 stated the alarm startled her because she thought there was an actual fire.During an interview on 9/16/25 at 2:38 p.m. with Resident 8, Resident 8 stated the fire alarm was really loud and that she was unaware of the test. Resident 8 stated, The alarm startles you when you are sleeping.During a review of the facility Fire Safety Service Invoice (FSS) dated 9/9/25, the FSS indicated, three fire tests were conducted on 9/9/25 10:45 A.M., 5:15 P.M. and on 9/10/25 at 3:00 A.M.During an interview on 9/16/25 at 3:35 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that there was a fire alarm test last week. CNA 1 stated she was notified about the fire alarm test but was not instructed to notify the residents.During a concurrent interview and record review on 9/18/25 at 11:21 a.m. with the DON, the facility P&P titled Testing of Fire Alarm System dated 05/2008 was reviewed. The P&P indicated .Notify all staff that the alarm is only a test . The DON stated residents should also be notified so they will not be startled and to keep them comfortable.During a review of the facility P&P titled, Quality of Life-Homelike Environment dated 05/2007, the P&P indicated, .Residents are provided with a safe, clean comfortable and homelike environment .comfortable noise levels .

Based on observation, interview, and record review, the facility failed to ensure that medications were stored securely and administered according to physician orders for one of 13 sampled residents (Resident 20) when staff left medication at Resident 20's bedside. This failure had the potential for misuse by the resident on unintended areas or for non-approved purposes. Findings:On 9/15/2025 at 3:50 p.m. a 30 milliliter (unit of measurement) medication cup with a white cream/ointment was observed on the shelf in Resident 20's room. The medication cup was not labeled.On 9/15/2025 at 3:56 p.m. during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 verified that Resident 20 did not have a physician order to keep any type of medication at bedside.During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility dated April 2008, the P&P indicated, ID4: Bedside Medication Storage.A. A written order for the bedside storage of medication is present in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in safe and sanitary conditions in the food service department, when the dry storage area contained food items that were undated. This failure had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings:During a concurrent observation and interview on 9/16/2025 at 2:00 p.m. with the Consultant Registered Dietitian (CRD), in the kitchen, there was a food container labeled Polenta with no expiration date. CRD stated the expectation was for staff to carefully inspect all food delivery, to label and to date food items. CRD further stated labeling and dating food items were necessary to prevent food-borne illnesses to the residents. During a review of the facility's policy and procedure (P&P) titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, the P&P indicated, Label all items with the delivery date or a use-by-date .

Based on interview and record review, the facility failed to ensure a facility-wide assessment (a review of a facility's infrastructure, resident population, and services to determine needed resources to provide care) was available, current, and complete. This deficient practice decreased the facility ' s potential to safely admit residents and ensure their care needs were met. Findings: During an interview on 1/17/24 at 1:58 p.m., a copy of the facility assessment was requested from the Director of Staff Development (DSD). The DSD stated the facility assessment was not available and was locked in the Administrator ' s office. During an interview on 1/21/24 at 10:25 a.m., the Infection Preventionist (IP) (who was also the interim Director of Nursing (DON)) stated she could not find the facility assessment. The IP stated she was putting one together over the weekend and what she had was incomplete. A review of the of the document provided to the surveyor on 1/21/24 did not follow the facility ' s policy and procedure for conducting, reviewing, and updating the facility assessment. During an interview on 1/21/24 at 3:30 p.m., the Administrator verified they could not find the facility assessment. During a review of the facility ' s Policy and Procedure titled Facility Assessment, revised October 2018 indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents day-to-day .The team responsible for conducting, reviewing and updating the facility assessment includes the following .The Administrator .A representative of the governing body .The medical director .The director of nursing services . Based on interview and record review, the facility failed to ensure a facility-wide assessment (a review of a facility's infrastructure, resident population, and services to determine needed resources to provide care) was available, current, and complete. This deficient practice decreased the facility's potential to safely admit residents and ensure their care needs were met. Findings: During an interview on 1/17/24 at 1:58 p.m., a copy of the facility assessment was requested from the Director of Staff Development (DSD). The DSD stated the facility assessment was not available and was locked in the Administrator's office. During an interview on 1/21/24 at 10:25 a.m., the Infection Preventionist (IP) (who was also the interim Director of Nursing (DON)) stated she could not find the facility assessment. The IP stated she was putting one together over the weekend and what she had was incomplete. A review of the of the document provided to the surveyor on 1/21/24 did not follow the facility's policy and procedure for conducting, reviewing, and updating the facility assessment. During an interview on 1/21/24 at 3:30 p.m., the Administrator verified they could not find the facility assessment. During a review of the facility's Policy and Procedure titled Facility Assessment, revised October 2018 indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents day-to-day .The team responsible for conducting, reviewing and updating the facility assessment includes the following .The Administrator .A representative of the governing body .The medical director .The director of nursing services .

Based on interview, and facility record review, the facility failed to have a Registered Nurse (RN) performing the function of the Director of Nursing (DON) on a full-time basis to provide oversight and guidance on the provision of care provided by nursing staff. This failure prevented the facility from having the required management, to adequately assess and meet the needs of residents in a timely manner and had the potential to negatively impact the quality of care delivered by licensed and non-licensed nursing staff to residents. Findings: During an interview on 1/17/25 at 12:35 p.m., Licensed Staff A stated there was no DON at the facility and there has not been a DON since November. Licensed Staff A stated the facility was advertising for a DON, but currently, there were no candidates. During an interview on 1/17/ 25 at 12:45 p.m., the Infection Preventionist (IP) stated the previous DON left at the end of November 2024. The IP also stated she currently occupied the full-time IP role and the interim DON role, until a permanent DON is hired. The IP confirmed she was a Licensed Vocational Nurse (LVN). During an interview on 1/21/ 25 at 3:30 p.m., the Administrator stated the DON left on 11/27/24 and the facility has been advertising for a new DON, but at-the-moment there were no candidates. When asked who was in charge, she stated the IP was the interim DON until a full-time DON could be hired. The Administrator stated RNs were scheduled on all work shifts, but none wanted the DON position. Review of the facility ' s job description titled Director of Nursing revised on 1/2/20 indicated, Qualifications .Registered nurse with a current license in community's state .B.S. [Bachelor of Science] Degree in nursing . Based on interview, and facility record review, the facility failed to have a Registered Nurse (RN) performing the function of the Director of Nursing (DON) on a full-time basis to provide oversight and guidance on the provision of care provided by nursing staff. This failure prevented the facility from having the required management, to adequately assess and meet the needs of residents in a timely manner and had the potential to negatively impact the quality of care delivered by licensed and non-licensed nursing staff to residents. Findings: During an interview on 1/17/25 at 12:35 p.m., Licensed Staff A stated there was no DON at the facility and there has not been a DON since November. Licensed Staff A stated the facility was advertising for a DON, but currently, there were no candidates. During an interview on 1/17/ 25 at 12:45 p.m., the Infection Preventionist (IP) stated the previous DON left at the end of November 2024. The IP also stated she currently occupied the full-time IP role and the interim DON role, until a permanent DON is hired. The IP confirmed she was a Licensed Vocational Nurse (LVN). During an interview on 1/21/ 25 at 3:30 p.m., the Administrator stated the DON left on 11/27/24 and the facility has been advertising for a new DON, but at-the-moment there were no candidates. When asked who was in charge, she stated the IP was the interim DON until a full-time DON could be hired. The Administrator stated RNs were scheduled on all work shifts, but none wanted the DON position. Review of the facility's job description titled Director of Nursing revised on 1/2/20 indicated, Qualifications .Registered nurse with a current license in community's state .B.S. [Bachelor of Science] Degree in nursing .

Based on observation, interview, and record review, the facility failed to ensure supervision to prevent accidents for one resident (Resident 1) when: 1. Resident 1 eloped from the facility and was found face down on the pavement; and, 2. The Wander Monitoring System (WMS, an alarm system compromised of a monitor placed on the resident and placed on facility exits used to prevent residents from wandering or seeking to leave the facility) ordered by the physician to be implemented for Resident 1 was not functional. These failures resulted in Resident 1 ' s obtaining trauma to the right eyebrow and a laceration which required stiches and decreased the facility ' s potential to ensure the safety of residents at risk of elopement to leave the facility undetected placing the resident at risk for injury or harm. Findings: 1. Review of Resident 1 ' s clinical record showed Resident 1 was admitted to the facility on [DATE], with a diagnosis which included Traumatic Subdural Hemorrhage (a collection of blood between the brain and skull caused by a head injury) and unspecified dementia (the loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 12/26/24, indicated a Brief Interview for Mental Status (BIMS) score of 6 which meant Resident had severe cognitive impairment. A review of a care plan regarding Resident 1 ' s high risk for falls related to dementia, impulsiveness, wandering, and poor safety awareness, initiated on 6/19/24, indicated, [Resident 1 ' s goal was to] not sustain .injury through the review date [of 3/1/25] .[Interventions staff were to implement to assist Resident 1 to meet her goal included] Encourage and assist [Resident 1] with remaining in common, supervised areas when awake [Initiated 1/10/25] .Provide resident a safe environment [Initiated 10/15/24] . A review of a care plan regarding Resident 1 ' s potential for impaired behavioral patterns, initiated on 10/25/24, indicated, [Resident 1 ' s goal was to] have no injury related to impaired behavioral pattern through review date [of 3/1/25] .[Interventions staff were to implement to assist Resident 1 to meet her goal included] Monitor/Record occurrence of targeted behavior [which included] Exit Seeking . A review of Resident 1 ' s progress note dated 1/12/25 at 11:06 p.m., indicated, [Resident 1] was found outside [the facility on] the pavement by facility staff around 19:40 hrs [7:40 p.m.] Staff notified this nurse and other care staff. [Resident 1] found on the pavement face down to ground, with bleeding noted on pavement .[Resident] was noted to be bleeding from the right top corner of eye, noted laceration to area with a hematoma . A review of the hospital history and physical dated 1/12/24, indicated Resident 1, .was found wandering outside without her walker and had fallen causing abrasion [damage to the skin caused by scraping] and trauma of the right eyebrow .She [has] extensive swelling of the right eye which is currently closed due to edema [when fluid accumulates in body tissues] .Assessment and Plan .[Resident 1] with .Closed head injury causing a right eyebrow laceration [a tear or cut in the skin] and significant right orbital [eye socket] ecchymosis [blood vessels damaged by trauma causing leakage to surrounding tissues] . A review of the hospital discharge summary dated 1/14/25, indicated Resident 1 was, Date of Discharge: 1/14/25 .Seen by trauma team [and had her] laceration sutured [stiches]. A review of the facility ' s policy and procedure titled Wandering and Elopements, revised March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm . 2. A review of Resident 1 ' s TAR dated January 2025 indicated Resident 1 had an order for licensed staff to, .check placement of [Wandering] Device .every shift- Start Date 1/17/25 at [7 a.m.] and -D/C Date- 1/22/25 at [6:37 a.m.]. During an interview on 1/17/25 at 1:20 p.m., the Infection Preventionist (IP) confirmed Resident 1 was wearing a WMS and the system was not fully functioning. The IP stated there was only one alarm for the entire facility which was located the front door. The IP also stated the two additional doors residents could exit from did not have alarms. The IP stated the maintenance department checked the alarm located at the exit, and nursing staff checked the monitor on the resident to ensure both components of the WMS worked. The IP stated the facility did not have a policy and procedure for maintenance testing of the WMS nor did the facility have the manufactures instructions for use. During an observation and concurrent interview on 1/17/25 at 4 p.m., Unlicensed Staff A stated this was her first evening taking care of Resident 1 and she was unaware Resident 1 had a WMS device. Unlicensed Staff A then lifted the resident ' s pant leg and observed a WMS device to Resident 1 ' s left ankle. During an interview on 1/17/25 at 4:15 p.m., Licensed Staff B stated she had just come on shift and was unaware Resident 1 was wearing a WMS device. Licensed Staff B stated the nurses test the alarm by taking the resident to the front door and maintenance monitored the function of the WMS system. During an interview on 1/21/25 at 1:48 p.m., the Maintenance Supervisor (MS) stated the facility ' s WMS was outdated and had been updating the system, but the update had been canceled. The MS stated he tested the WMS front door alarm on a weekly basis but did not change the batteries to the WMS device and did not know who changed them. During an observation on 1/21/25 at 2:30 p.m., the two facility exit doors (one in the back of the facility and one on the side of the facility) did not have WMS alarms to alert staff when a resident was exiting the building. Review of Resident 1 ' s elopement evaluation conducted on 1/22/25, indicated, .Has the Resident verbally expressed the desire to go home .[answer checked] No .Is the wandering behavior a pattern, goal-directed (i.e. confused, moves with purpose .) [answer checked] No .Has the Resident been recently .readmitted (within the past 30 days) and is not accepting the situation .[answer checked] No . Further review of this document indicated the options in section Clinical Suggestions were not chosen at all. In an interview and concurrent record review with the Infection Preventionist on 2/10/25 at 3:10 p.m., the IP verified all monitoring in January 2025 for Resident 1 was documented on her TAR. The IP also confirmed the clinical suggestions section of Resident 1 ' s elopement evaluation form dated 1/22/25 was incomplete. The IP stated it should have been completed. A review of Resident 1 ' s TAR dated January 2025 indicated Resident 1 had an order for licensed staff to, .Check placement, functioning and integrity on left ankle .every shift for 30 Days- Start Date 1/22/25 at [7 a.m.] . In an interview on 2/12/25 at 11:33 a.m., the IP confirmed there was no documented evidence visual checks were done on 1/14/25 and 1/15/25 for Resident 1. The IP also verified the facility did not have a policy and procedure for the use of the WMS and stated the facility should have one. The IP further stated the facility is working on getting a policy written.

Based on observation, interview, and record review, the facility failed to ensure patient care equipment was functioning and maintained under sanitary conditions when oxygen therapy equipment provided to facility residents was dirty and not maintained. This failure decreased the facility ' s potential to prevent infections among respiratory compromised residents who used oxygen concentrators for medical treatments. Findings: During an interview on 1/21/25 at 1:48 p.m., the Maintenance Supervisor (MS) stated he checked the oxygen storage room periodically to ensure the oxygen tanks were secure. The MS also stated he did not have oversight nor did any maintenance on the oxygen concentrators and was unsure who maintained the oxygen concentrators. During an observation and current interview on 1/21/25 at 2:00 p.m., the Infection Preventionist (IP) stated she tracked all residents on respiratory therapy and any respiratory infections that occurred in the facility. The IP stated there were currently six residents on oxygen therapy who used oxygen concentrators provided by the facility. An observation of the oxygen storage room and concurrent interview on 1/21/25 at 2:15 p.m., showed multiple oxygen tanks were not secured or in a rack (unsecured oxygen tanks can be dangerous and cause serious injury or death by tipping over and shear the valve or a pressurized cylinder to explode from a mechanical failure). Three oxygen concentrators were observed to have dust covering the top and front of the oxygen concentrators. The sides of one concentrator had filters that were full of lint and debris. On one oxygen concentrator the last date of maintenance service performed was 3/25/20. The IP verified the concentrators were dirty and stated she did not know who was responsible for cleaning and maintaining the concentrators. IP stated she was in the process of establishing a clean and dirty location for the oxygen concentrators. During a continued interview on 1/21/25 at 2:30 p.m., the IP verified there was no maintenance contract for service of the oxygen concentrators. A request for a policy and procedure and instructions for use (IFU) for the maintenance of the oxygen concentrators was requested but not provided. A review of the manufactures instructions for use (IFU) for the oxygen concentrators, indicated, routine maintenance and cleaning of the oxygen concentrators following a preventative maintenance record. Based on observation, interview, and record review, the facility failed to ensure patient care equipment was functioning and maintained under sanitary conditions when oxygen therapy equipment provided to facility residents was dirty and not maintained. This failure decreased the facility's potential to prevent infections among respiratory compromised residents who used oxygen concentrators for medical treatments. Findings: During an interview on 1/21/25 at 1:48 p.m., the Maintenance Supervisor (MS) stated he checked the oxygen storage room periodically to ensure the oxygen tanks were secure. The MS also stated he did not have oversight nor did any maintenance on the oxygen concentrators and was unsure who maintained the oxygen concentrators. During an observation and current interview on 1/21/25 at 2:00 p.m., the Infection Preventionist (IP) stated she tracked all residents on respiratory therapy and any respiratory infections that occurred in the facility. The IP stated there were currently six residents on oxygen therapy who used oxygen concentrators provided by the facility. An observation of the oxygen storage room and concurrent interview on 1/21/25 at 2:15 p.m., showed multiple oxygen tanks were not secured or in a rack (unsecured oxygen tanks can be dangerous and cause serious injury or death by tipping over and shear the valve or a pressurized cylinder to explode from a mechanical failure). Three oxygen concentrators were observed to have dust covering the top and front of the oxygen concentrators. The sides of one concentrator had filters that were full of lint and debris. On one oxygen concentrator the last date of maintenance service performed was 3/25/20. The IP verified the concentrators were dirty and stated she did not know who was responsible for cleaning and maintaining the concentrators. IP stated she was in the process of establishing a clean and dirty location for the oxygen concentrators. During a continued interview on 1/21/25 at 2:30 p.m., the IP verified there was no maintenance contract for service of the oxygen concentrators. A request for a policy and procedure and instructions for use (IFU) for the maintenance of the oxygen concentrators was requested but not provided. A review of the manufactures instructions for use (IFU) for the oxygen concentrators, indicated, routine maintenance and cleaning of the oxygen concentrators following a preventative maintenance record.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan with measurable objectives and appropriate interventions for one resident (Resident 1), that addressed fall precautions when the resident developed an L3 fracture (a fracture of the third vertebra in the lumbar spine) of unknown origin. This failure put Resident 1 at risk for additional injuries and falls and had the potential to cause pain and Resident 1's safety to go unmonitored. Findings: During an interview on 7/22/24 at 10:15 a.m., the DON (Director of Nursing) stated she followed-up on Resident 1's abdominal pain by sending the resident to the hospital where an X-ray and blood test confirmed Resident 1 had an L3 fracture and Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). The DON stated she looked back in the medical records and found a bone density test that was performed in 2015 and confirmed Resident 1 was diagnosed with Osteoporosis. While in the facility the DON was asked if Resident 1 had any falls , she stated the resident had No falls. During a review of the clinical record for Resident 1, the Admission Record (demographic information), indicated Resident 1 was admitted on [DATE], with a medical diagnosis that included: Age-related Osteoporosis without current pathological fracture, Dysphagia (a condition that affects your ability to produce and understand spoken language), Aphasia (a language disorder that affects a person's ability to communicate due to damage to the brain's language centers) following unspecified cerebrovascular disease (damage to the blood supply to the brain), and Hemiplegia and Hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness on one side of the body) following cerebral infarction (or brain infarction, is the death of brain tissue caused by a prolonged decrease in blood flow to the brain) affecting right dominant side and difficulty in walking not elsewhere classified. During an interview on 7/22/24 at 11:00 a.m., the Director of Rehabilitation stated Resident 1 had therapy 5 times per week, (Physical, Occupational, and Speech Therapy). He stated the resident had a stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) and as part of her plan for therapy a Hemi walker (a small mobility aid that helps people with limited or no dexterity in one hand or side of their body, walk) was used for working on gait and endurance. When asked if Resident 1 had any falls since her admission to the facility, the director of rehab stated the resident had no falls in the facility. When asked if the resident's therapy is care planned and if the CNAs and staff know how to properly continue treatment and follow a plan of care for this resident he stated Yes. When asked how the plan of care was communicated to the staff, he stated the CNAs were shown and told what to do. Review of Resident 1's care plan indicated Resident 1 had an unwitnessed fall in her room on 6/16/24 and did not show specific interventions or monitoring to prevent falls from occurring. This fall could have potentially caused the L3 fracture and pain, but there was no documemtation to support this finding. During an observation and concurrent interview on 7/22/24 at 11:30 a.m., Resident 1 was observed sitting in a wheelchair in the activity room. When attempting to interview Resident 1 she could not verbalize or form words or sentences to questions asked; movement was weak to her right side. When asking the resident if she had pain, she attempted to answer the question, but words were scrambled and incomprehensible. She shook her head No. A review of Resident 1's Minimum Data Set 3.0 (MDS- a standardized assessment and screening tool) dated June 8, 2024, did not show a complete assessment for level of cognition (mental process of thinking and understanding) was conducted the assessment form was missing data points and did not include a Brief Interview for Mental Status (BIMS) summary score in-order to confirm if Resident 1 was able or unable to make herself understood or if she was able to understand others. A review of Resident 1's fall assessment evaluation dated June 9, 2024, was also incomplete with missing data points and showed no risk level for falls or interventions to assist the resident with ambulation and transfers. During an interview on 7/22/24 at 11:45 a.m. the Charge Nurse was assigned to take care of Resident 1 and was asked what interventions were in place to help prevent falls for the resident. She stated all residents had gait belts that Physical Therapy (PT) used when walking residents, we bring fall risk residents to the nurse's station or to the activity room to keep a watch on them. When asked if the interventions were care planned, she stated she would have to look at the care plan. Review of the care plan did not show specific interventions for fall risk were listed in the care plan nor were any updates made to the care plan post hospitalization . When asking the charge nurse how she kept residents safe from falls she stated we do frequent checks and keep the residents at the nurse's station. When asked if the monitoring of falls was documented in the progress notes or on the Treatment Administration Record (TAR), she stated it usually was. When reviewing the TAR and care plan no interventions or monitoring was listed for Resident 1. During an interview on 7/22/24 at 12:00 noon, the DON was asked how residents were kept safe from falls. She stated we post signs at the bedside that lets staff know how to move residents out of bed. When asked what interventions were put in place to monitor Resident 1 for falls, she stated she would have to look at the care plan. Review of Resident 1's care plan showed no specific interventions were listed on the care plan to prevent falls for Resident 1. The DON stated to the charge nurse that monitoring interventions for falls should be added to the care plan for Resident 1. The DON showed a copy of the Safety-First sign posted on the wall next to Resident 1's bed with instruction that indicated, resident transfers required, moderate and maximum assist and when standing pivot transfer to the left, right side is weak. A review of the facility's policy and procedure titled, Care Plans- Comprehensive Person-Centered with a revision date of December 2016, indicated: 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; h. Incorporate risk factors associated with identified problems; . m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels .13. Assessment of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

Based on observation, interview and record review, the facility failed to honor (Resident 1) choice for the refusal of end-of-life medical treatment. This failure resulted in Resident 1 receiving Cardiopulmonary conversion (chest compressions) and mechanical ventilation (assisted breaths with a medical device) against Resident 1's decision. During a review of Resident 1's medical record, Physician Orders for Life-Sustaining Treatment (POLST) form, dated [DATE], indicated in box A, Do Not Attempt Resuscitation / (DNR) (Allow Natural Death), Box B indicated, Comfort -Focused Treatment - primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full treatment (mechanical ventilation and cardioversion) and Selective Treatment unless consistent with comfort goal. Request transfer to hospital only if comfort needs cannot be met in current location. Box D indicated, signature of legally recognized decision maker 1 and MD 2. During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff A, indicated, Legally recognized decision maker 1 has changed POLST to DNR (Do not resuscitate) comfort focus. During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff B, indicated, MD aware of DNR Comfort Care and an IDT (interdisciplinary meeting for Comfort Care). During a review of Resident 1's medical record, Progress note dated [DATE], signed by Licensed Staff C, indicated, at 4:40 p.m., resident was found with no vital signs and Licensed Staff C started performing CPR (cardiopulmonary conversion) also using AED - Automated Electronic Defibrillator (medical device that shocks the heart with intent to start the heart beating again.) Fire dept arrived and EMT's (Emergency Medical Technicians) took over the CPR using AED and Ambu Bag. (medical device bag that fills with oxygen and then pumps oxygen into the residents nose and mouth). Resident 1 was pronounced dead at 5:21 p.m. Legally recognized decision maker 1 arrived at the facility at 5:30 p.m. During an interview with Licensed Staff C on [DATE] at 1 p.m., Licensed Staff C stated, she was Resident 1 primary nurse on [DATE] and when Resident 1's heart and respirations stopped. Licensed Staff C stated, she immediately checked Resident 1's chart for the POLST but the chart only contained a previously dated POLST from [DATE]. Licensed Staff C stated, she thought that the POLST in the chart was the most up to date. Licensed Staff C stated, she did not realize there was a more recent version of Resident 1's POLST dated after [DATE]. Licensed Staff C stated, the POLST she followed from [DATE] indicated DNR with Full Treatment (mechanical ventilation and cardioversion). Licensed Staff C stated this is why she performed the CPR on Resident 1. Licensed Staff C queried what the risk to resident safety are if an outdated POLST is left on the front of Resident 1's Chart. Licensed Staff C stated, she thinks that the latest wishes of the resident and / or Resident representative would not be honored as they should. During an observation and record review of Resident 1's medical record, indicated there was a prior POLST dated, [DATE], for Resident 1 that indicated in Box B, DNR with Full Treatment. Box D of the POST was signed by Legally recognized decision maker 1 and MD 1. During an interview with Unlicensed Staff D, on [DATE] at 2:15 p.m., Unlicensed Staff D stated, she is the manager of the facilities Medical Records Department whose job it is to place the resident's POLST form in the front of the hard copy of the chart where it is easily accessible. Unlicensed Staff D stated, she was on vacation at that time and the most recent version of the POLST never made it into Resident 1's chart. Unlicensed Staff D then stated, she was not on vacation, but doesn't understand how the most recent POLST did not make it to Resident's 1 Hard copy of the chart. During an interview with the DSD, on [DATE] at 2:25 p.m., DSD queried if she was aware of the POLST policy. DSD stated, she was aware of the POLST policy. DSD queried for the in-services that she performed for the nursing staff in the last 3 months. No in-services for nurses were completed by the DSD for the facility's POLST Policy, DNR policy or Crash Cart policy and procedures. During an interview with the DON on [DATE] at 2:40 p.m., DON was queried why the latest POLST was not in the front of the chart for Resident 1. DON stated, she knows it is the facility's policy to keep the latest POLST in the front of the hard copy of the chart. DON stated, she is unaware as to how the latest POLST for Resident 1 was not in the front of the hard copy of the chart when Resident 1 expired. During a review of the DSD's job description, titled, Director of Staff Development, updated 2015, indicated, Essential Duties and Responsibilities, 5. Assists in the planning and coordination of training programs for all departments within the facility to respond to identified problem areas, service quality or to teach procedures or methods. 7. Provide-specific orientation to Health Center nursing staff including completion of the clinical skills checklist. 20. Assumes a proactive role in resolving resident issues & concerns related to assigned areas of responsibility. During a review of the facility's policy and procedure titled, Do Not Resuscitate Order Revised [DATE], indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DO NOT Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident' medical record. 6. The Interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 7. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 8. Inquiries concerning do not resuscitate orders / requests should be referred to the administrator, director of nursing services, or to the social services director. During a review of the facility's policy and procedure titled, Resident Rights Guidelines for All Nursing Procedures Revised 2010, indicated, 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: C. Resident notification of rights, services and health/medical condition, F. Resident right of refusal (medication and treatments), H. Resident freedom of choice, I. Resident/Family participation in care planning. During a review of the facility's policy and procedure titled, Advance Directives Revised [DATE], indicated, H. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form-a form designed to improve patient care by creating a portable medical order from that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. Refusing or Requesting Treatment 1. The resident has the right to refuse medical or surgical treatment, whether or not he or she has an advance directive. A. A resident will not be treated against his or her own wishes. B. Residents who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met. C. The resident's refusal does not absolve facility staff from providing other care that allows him/her to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. 2. Depending on the state requirements, the legal representative may also have the right to refuse or forego treatment. 3. If the resident or representative refuses treatment, the facility and care provider will: C. Document specifically what the resident/representative is refusing. 7. The Staff Development Coordinator is responsible for scheduling training regarding advance directives for newly hired staff members as well as scheduling annual advance in-services to ensure that the staff remains informed about the residents' rights to formulate advance directives and facility policy governing such rights.

Based observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety when: 1) the facility failed to store dry foods (staples; mixes and packaged foods; canned and dried foods; spices, herbs, condiments, and other foods not requiring refrigeration) in the optimum temperature between 50 and 70 Fahrenheit (F); and 2) the facility failed to prevent cross-contamination of kitchen dishes when dietary staff operating the dishwasher handled dirty and clean dishes without changing gloves or performing hand hygiene. These failures had the potential for residents to consume degraded food and had the potential to expose residents to gastro-intestinal diseases. Findings: 1) During an observation on 5/30/24, at 3:20 p.m., the dry foods storage felt warm. There was no thermometer in the dry foods storage. During a concurrent interview, the Dietary Services Manager (DSM) was asked to check the room temperature in the dry foods storage. The DSM stated there was no thermometer available to check the temperature in the dry foods storage. The surveyors ' thermometer registered 85 F in the dry foods storage. The DSM stated dry foods should be stored at temperatures between 68 and 75 F. A review of the label of a bottled oil spray in the dry foods storage indicated to store it in a cool place between 68 and 75 F. A review of facility policy titled DRY STORAGE CHART, dated 2023, indicated: The optimum storage temperature for dry foods is 50 to 70 F. 2) During an observation on 5/30/24, at 3:45 p.m., Dietary Staff A (DS A) was operating the dishwasher. DS A, wearing gloves, loaded a rack with dirty dishes and placed it in the dishwasher. DSA A initiated the washing cycle and at the end removed the clean dishes from the dishwasher using the same gloves used to load the dirty dishes. DS A did not change gloves or performed hand hygiene in between handling the dirty and clean dishes.

Based on observation, interview, and record review, the facility failed to report one incident of resident abuse to authorities within the required two-hour time frame after the allegation was made. This failure to report an allegation of abuse within the Federally mandated requirement of two hours, had the potential to result in ongoing resident abuse and physical, mental, and /or emotional harm, and prevented the State Agency from conducting a timely investigation into the allegation. Findings: During a review of a report titled State of California Report of Suspected Dependent/Elder Abuse (SOC 341) dated 1/1/24, the SOC 341 indicated alleged abuse occurred on 12/30/23 with exact time unknown. The SOC 341 indicated telephone report made to the State Agency and Local Ombudsman on 12/31/23 at 12:15 p.m. and written report was faxed 1/1/24 at 10:49 a.m. During a review of a document titled SOC 341 General Instructions, dated 8/22, Instructions indicated, If the abuse occurred in a Long-Term Care (LTC) facility, was physical abuse, but did not result in serious bodily injury .send the written report to the local law enforcement agency, the local Long term Care Ombudsman Program (LTCOP), and the appropriate licensing agency within 24 hours of observing, obtaining knowledge of, or suspecting physical abuse. During a review of a document titled Abuse Allegation Follow-Up Report, dated 1/3/24, the Follow-Up Report indicated, On Sunday, December 31st, verbally reported this allegation to CDPH, and the local Ombudsman, and faxed the SOC 341 on Monday, January 1st, 2024. During an interview on 1/10/24 at 9:00 a.m., the Director of Nursing (DON) stated abuse incident occurred when alleged perpetrator (contracted vendor staff) sitter (a non-licensed staff hired to provide companionship and did not provide direct patient care) allegedly hit Resident 1 (R1). DON stated the alleged victim, R1, had a 1:1 sitter for safety reasons due to impulsivity and throwing things. The DON stated the alleged perpetrator no longer worked at the facility. The DON stated the Certified Nursing Assistant A (CNA A) reported the alleged abuse to the Director of Staff Development (DSD) on 12/31/23. During an interview on 1/10/24 at 9:45 a.m., the Administrator stated verbal report of abuse was made to the California Department of Public Health (CDPH) and the Ombudsman on 12/31/23. The Administrator was unable to provide time or documentation of verbal reporting. During the same interview on 1/10/24 at 9:45 a.m., the Administrator stated Abuse and Neglect training was completed upon hire, annually, and as needed. The Administrator trained all staff on December 5, 2023, on abuse, including reporting and the State of California form Report of Suspected Dependent/Elder Abuse (SOC 341). Administrator stated if abuse did not result in bodily injury reporting was within 24 hours and if it did result in bodily injury, we reported within two hours and followed up with a written report. The Administrator stated the outcome of the abuse investigation was unsubstantiated. (Unsubstantiated does not mean it did not happen, it means there was not enough evidence to prove it happened.) During an interview on 1/10/24 at 10:10 a.m., the DSD stated CNA A called her at home on 12/31/23 to report allegation of abuse had occurred on 12/30/23. During an interview on 1/10/24 at 10:15 a.m., the DSD stated, we reported to the Administrator and the DON as soon as we were aware. The DSD stated reporting times were, I think 36 hours, two days. DSD stated she got information about alleged abuse over the phone from CNA A on 12/31/23. DSD stated she called the facility, the DON, the Administrator, the contracted vendor which employed the alleged perpetrator, and left voice messages for the State Agency and the Ombudsman. During a review of a document titled Written Statement from LN A, dated 1/9/24, statement indicated, CNA A verbally reported alleged abuse to her on 12/30/23 at around 1100 a.m. LN A further stated, I did not do incident reporting as CNA A called the DSD and reported this claim to her the following morning. Document further stated, I will make a report ASAP if witnessed abuse happened, reporting right away within 4-6 hours and papers documentation filed within 24-48 hours to local authorities. During a review of a document titled Elder Justice Act Notice to Employees, dated 11/07/11, Notice indicated, Reports of the reasonable suspicion of a crime against a resident of the Health Center must be made to the California Department of Public Health and local law enforcement entity within 2 hours if there is serious bodily injury. If events causing the suspicion do not result in serious bodily injury, it must be reported within 24 hours after forming the suspicion. This document is included in the current Facility Orientation and Abuse Packet. During a review of a document titled Arbol Residences of Santa [NAME] Abuse Prevention Policy, dated 05/07/12, indicated, If a resident sustains a serious bodily injury the law enforcement agency and the California Department of Health (707-576-6775) must be contacted within two hours of forming the suspicion. If the resident ' s injury is not serious, the law enforcement agency and the California Department of Public Health must be contacted within 24 hours after forming the suspicion. This document is included in the current Facility Orientation and Abuse Packet.

Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) meat not thawed according to the facility's policy and procedure, 2) the correct Cool Down Process for cooked meats was not followed per the facility's policy and procedure, 3) dietary staff did not know how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solutions, 4) non-pasteurized eggs were being used, 5) the kitchen floors and counter appliances looked dirty, 6) garbage cans in the prep food areas were not covered with lids and the garage bens outside were open and there was garbage surrounding the garbage bins, 7) opened dried food products were not labeled with an open date and use by date, 8) fresh produce located in bins in the refrigerator were not labeled with a received by date, 9) spoiled produce was not thrown away, 10) the high temperature dishwasher wash cycle was not running per the manufactures recommendation, 11) a portion of the kitchen wall near the ovens was not repaired, and 12) tiles were missing from the refrigerator to freezer door threshold of the walk-in refrigerator/freezer, blackened areas where the floor tiles were missng and the coupling was pulling away from the freezer side of the doorframe. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: During the course of the survey from [DATE]-[DATE] through observations, interviews and dietary record reviews related to deficient practices in food service systems were noted, affecting all residents. These included: 1. Failure to ensure safe dietetic services as evidence by dietary staff not thawing meat according to the facility's policy and procedure (Cross Reference F802). 2. Failure to ensure safe dietary services as evidence by dietary staff not using the correct Cool Down Process for cooked foods and ambient food items like tuna for tuna salad (Cross Reference F802). 3. Failure to ensure safe dietary services as evidence by dietary staff not knowing how to test the quat sanitizer solution (Cross Reference F802). 4. Failure to ensure safe dietary services as evidence by dietary staff serving non- pasteurized eggs to residents (Cross Reference F802). 5. During the initial tour of the kitchen on [DATE] at 9:50 a.m., the kitchen floors including the food pantry floor looked dirty, the toaster had crumbs all over it, and the food processor looked spotty with food particles. During an observation on [DATE] at 10: 40 a.m., the kitchen floors looked dirty throughout the kitchen. The toaster had crumbs all over it, and meat slicer, mixer and food processor had food particles/splatter on them. None of the appliances were covered. During an interview on [DATE] at 3:55 p.m., the Food and Beverage Manager stated the Dietary Manager was in charge of production of the kitchen. The Food and Beverage Manger stated he along with the Dietary Supervisor did the deep cleaning of the kitchen. All dietary staff have cleaning assignments pertaining to the area of the kitchen they work. The Food and Beverage Manager stated cleaning this kitchen was a delicate subject with the dietary staff, so he and the Dietary Manger just did the weekly deep cleaning. The Food and Beverage Manger stated cleaning was built into the dietary staffs' position. The Food and Beverage Manager did not know if the kitchen appliances were cleaned thoroughly all the time. The Food and Beverage Manager stated there was a high turnover in the kitchen, so it was easier for him to clean the kitchen or the cleaning did not get done. During an interview on [DATE] at 3:30 p.m., the Food and Beverage Manager was asked to provide the kitchen cleaning logs [DATE] through [DATE]. A review of the Cooks Closing Cleaning log, indicated there were no logs maintained or provided for ,d+[DATE] through [DATE]. Starting [DATE] through [DATE], there were multiple days where Cooks Closing Cleaning Logs were not filled out to indicating if the cook completed their cleaning duties, which included, clean, sanitize and cover slicer, clean and cover stand mixer, sanitizer logs filled out for the day, and floors swept and mopped, amongst other duties. A review of the Dishwasher Closing Cleaning Logs, dated [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], indicated there were 23 days when the Dishwasher Closing Cleaning tasks were not done, 50 times when the kitchen floors were not swept and mopped and various other duties were not completed, and the week of [DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], and [DATE]-[DATE], there were no Dishwashing Closing Cleaning Logs to showing any of the dishwasher duties were completed. During an interview on [DATE] at 10:15 a.m., the Food and Beverage Manager stated he oversaw all three areas of the facility, which included the SNF unit. The Food and Beverage Manager stated he had no background in the Food and Nutritional Services for SNFs. The Food and Beverage Manager stated this was why there is a CDM, who also does the Dietary in-services regarding the SNF Dietary Regulations and Title 22 (California Code of Regulations). The Food and Beverage Manager stated the cooks did not have time between prepping and cooking to clean their areas. The Food and Beverage Manager stated the dishwasher was supposed to sweep and mop the kitchen. The Food and Beverage Manger stated he really did not know SNF regulations. He had been a chef at five-star restaurants. The Food and Beverage Manger stated he just initiated a cleaning schedule and cleaning log on ,d+[DATE]. The food and Beverage Manager stated he did not know he was supposed to maintain cleaning logs. When the Food and Beverage Manager was asked how he could prove the various areas of the kitchen had been cleaned/sanitized daily without cleaning logs, the Food and Beverage Manger stated he understood. During an observation and based on pictures on [DATE] at 1:22 p.m., an opened garbage can to the right of the ice bin was placed against the ice machine near the ice bin. The right side of the ice machine looked dirty/splattered as well as the surrounding kitchen floor. A review of the of the kitchen log titled, Ice Machine - Monthly Sanitizing Log, ,d+[DATE]-,d+[DATE], the ice machine was sanitized monthly. Note: Daily was crossed out and Monthly was written in. The facility dietary document titled, Daily and Weekly Cleaning Schedule, revised [DATE], indicated: Weekly duties included for the ice machine bin to be washed and sanitized. There were no Weekly Ice Machine Logs and no Daily and Weekly Cleaning Schedules initiated with signatures presented, to indicate the ice machine bin was washed and sanitized weekly. During an observation and based on pictures on [DATE] at 1:29 p.m., ants were crawling up and down the kitchen wall, left of door trim leading into food pantry, across from the office. The facility policy/procedure titled, Cleaning Schedules, revised [DATE], indicated: Policy: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional . Procedure: 1. The Director of Food and Nutrition Services or other qualified nutrition professional shall record all cleaning and sanitation tasks for the Food and Nutrition Services Department. 2. A cleaning schedule shall be posted with tasks designated to specific positions in the department. 3. All tasks shall be addressed as to frequency of cleaning. 4. The procedures to be used are listed in this Policy and Procedure Manual. 5. General Daily Cleaning Schedules and weekly cleaning schedules may be used or Cleaning Schedules (FORMs 751, 752, and 753 or other designated) form by position may be used. 6. On the Position cleaning schedules the Director of Food and Nutrition Services or other clinically qualified nutrition professional fills in the Position, the item to be cleaned, Frequency i.e. daily, day of week, or week 1, 2, 3, 4. 7. Under the days of the week or the weeks, the Director of Food and Nutrition Services or other clinically qualified nutrition professional can check off assignments completed or the employee can initial . The facility policy/procedure tilted, Food Processor, revised [DATE], indicated: . 4. An absorbent cloth and mild detergent may be used to wipe the base clean . Note: This policy applies to food processors and similar products . The facility policy/procedure titled, Blender, revised [DATE], indicated: . Sanitation of Equipment: . 6. Wash base with sanitizing solution and clean cloth. 7. Move machine base and sanitize table with sanitizing solution and clean cloth . The facility dietary document titled, Daily and Weekly Cleaning Schedule, revised [DATE], indicated: Daily duties included cleaning the food processor/blender, toaster, mop kitchen, office storeroom and walk-in refrigerator/freezer floors, mop bucket empty and clean, Mops wash and clean, wipe walls in cooks' area, wash garbage cans and lids, all counters and cook's tables, amongst other duties. 6. During the initial tour of the kitchen on [DATE] at 10:40 a.m., the garbage cans by the food prep sink under the prep counter had no lids. During an observation on [DATE] at 9:15 a.m., the garbage cans used on the clean side of the kitchen did not have lids. During an interview on [DATE] at 3:55 p.m., the Food and Beverage Manager stated they have never covered the garbage cans located on the clean side of the kitchen, for prepped food waste. During an observation on [DATE] at 10:15 a.m., the garbage cans located on the clean side of the kitchen did not have lids. The facility had two garbage dumpsters, both dumpsters' lids were up, and there was trash surrounding the dumpsters. Note photos were taken of the garbage dumpsters on [DATE] at 10:37 a.m. The right dumpster still had a lid up. The facility policy/procedure titled, Garbage and Trash Cans, revised [DATE], indicated: Sanitation of Equipment: 1. All food waste must be placed in covered garbage and trashcans . 4. Each time the garbage and trash are emptied, the containers are to be thoroughly inspected inside and out and cleaned, if needed, with a hot detergent solution and then rinsed. 5. The dumpster area must be free of debris on the ground and the lid must be closed . 7.-9. During the initial tour of the kitchen on [DATE] at 9:50 a.m. the bananas stored in the food pantry looked brown, the dispenser of white dried beans and quinoa grain and the opened spices of whole celery, pumpkin spice, and nutmeg were not labeled with an open date. The Dietary Manager stated once a spice was opened, the container should be labeled with an opened date. The bins of fresh fruits and vegetables including carrots and cabbage located in walk-in refrigerator did not have have a received by date. Some of the red bell peppers had black spots and some of the strawberries in their original containers were moldy. The Dietary Manager stated normally fruits/vegetable bins would be dated indicating the received by date. During an observation on [DATE] at 10:40 a.m., the opened nutmeg, clover and celery salt spices stored over prep table were not labeled with an opened date. During a concurrent observation and interview on [DATE] at 9:15 a.m., the dry goods bins stored under the large portable medal table next to prep counters, which stored couscous, jasmine rice and breadcrumbs were not labeled. The dry goods bins stored under the counter where the prep appliances were located, which held rolled oats, sugar and flour were not labeled. The Dietary Manager stated all the dry goods bins should have been labeled with an open and use by date. During an interview on [DATE] at 9:30 a.m., the Food and Beverage Manager stated all food products should have been labeled. The Food and Beverage Manager stated the food products should be labeled with a received by date, an open date and use by date. The food and Beverage Manager stated he had a gun to tag all food products with the date they came in. The Food and Beverage Manger stated milk needed an open date and should be thrown away after 14 days but based on the use by date on the container of milk. The Food and Beverage Manger stated all other dairy products were to be held no more than seven days after opened. The Food and Beverage Manager stated the fruit/vegetable produce bins stored in the refrigerator should have the date the produce came in. A review of the dietary document titled, Refrigerated Storage Quick Reference Guide, revised [DATE], indicated: Refrigerated food products stored in the refrigerator at ,d+[DATE] degrees Fahrenheit or less. Once whole or low-fat milk opened, store for one week. Berries stored unopened for one to two days. Carrots and red and green peppers one to two weeks. Heads of cabbage stored for one week. Fresh Fruits . 5. Most fruits should be used within 3 to 5 days . The facility policy/procedure, Food Storage, revised [DATE], indicated . Procedure: All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use Use-By dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts (POLs 154a, 154b, 154c) found in this section. Refrigerated Storage Quick Reference Guide (DOC 409) may be used for a more efficient method of noting use by dates on products . Remember to cover, label, and date! A label may not be needed if in original packaging and product is identified on the package. Any expired or outdated food products should be discarded . 10. During a concurrent observation, interview, and review of the high temperature dishwasher temperature recommendation for the wash cycle posted on the dishwasher machine and the Dish Machine Temperature Logs on [DATE] at 9:10 a.m., the Food and Beverage Manager checked the temperature of the wash and rinse cycle of the high temperature dishwasher. The Food and Beverage Manager stated the wash cycle temperature was 142 degrees Fahrenheit, The manufactures recommendations posted on the machine indicated the wash cycle temperature should be a minimum of 160 degrees Fahrenheit. The Dish Machine Temperature Log, dated ,d+[DATE], indicated the high temp wash cycle was running 133 to 139 degrees Fahrenheit. The Food and Beverage Manager was going to have a service professional come out to look at the dishwasher. During a concurrent observation and interview on [DATE] at 10:15 a.m., the Food and Beverage Manager stated the dishwasher had a booster to heat the water faster and the booster heated the wash cycle to 185 degrees Fahrenheit. Dietary Aide S stated he checked and logged the high temperature dishwasher temperatures for the wash and rinse temperature cycle first thing in the morning, so the hot water may not have been heated all the way. The Food and Beverage Manager stated the service technician gave him test strips to check the wash cycle temperature. The Food and Beverage Manager placed a test strip on a plate and ran the dishwasher. The Food and Beverage Manager stated if the test strip turned pink, which it did, the temperature of the wash cycle supposedly reach 160 degrees Fahrenheit, though the wash cycle temperature gauge never reached 160 degrees Fahrenheit. The Food and Beverage Manger stated the wash cycle temperature gauge must be off. A review of the dietary documents titled, Dish Machine Temperature Log, dated ,d+[DATE]-,d+[DATE], indicated the wash cycle temperature ran as low as 110 degrees Fahrenheit and only one time did it run at 160 degrees Fahrenheit. The majority of the times, the wash cycle ran in the 130s degree Fahrenheit. 11. During a concurrent observation and an interview on [DATE] at 11:50 a.m., the was a blue tarp covering the lower kitchen wall to the right of the ovens. The Food and Beverage Manger stated there was water damage from a busted pipe, which was fixed. Note photos were taken on ,d+[DATE] at 11:58 a.m. 12. During concurrent observation and interview on [DATE] at 12:05 p.m., the walk-in refrigerator/freezer had floor tiles missing from the refrigerator to freezer door threshold, blackened areas where tiles were missing on the floor of walk-in the refrigerator/freezer, and the coupling was pulling away from the wall on the freezer side of the doorframe. Note photos were taken on [DATE] at 12:03 p.m. During an interview on [DATE] at 03:32 p.m., the Registered Dietician (RD) stated the damage to the wall in the kitchen was because of a busted pipe. The RD stated both the wall damage and the repair needed in the walk-in refrigerator/freezer: tiles/frame of door leading between the refrigerator and freezer was in the works to be repaired. The RD state the Interim Administrator for the entire facility was working on the repair. The facility job description titled, Director of Food and Beverage Services, updated ,d+[DATE], indicated: General Summary: The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training, and supervising all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. Principle Duties: Essential Job Duties: 1. Organizes, directs and supervises all dietary service functions in consultation with the Dietitian; 2. Maintains established dietary standards and policies and assists the Dietitian in establishing and revising dietary policies and procedure . 8. Assures efficiency of food preparation and serving; compliance with local, state and federal standards; sanitation, and hygiene and health standards of personnel. 9. Oversees the selection, training, evaluating and disciplining of all dietary personnel . 11. Delegates authority to supervisory staff for task details to facilitate smooth flow of materials and services. Other Duties: . 5. Keeps appropriate records . 6. Monitors the care and the safe and sanitary use of supplies and equipment and all infection control policies and procedures . 8. Attends in-service training and education sessions as assigned . The facility job description titled, Dietary Manager, updated ,d+[DATE], indicated: General Summary: The Health Center Dietary Manager is responsible for overseeing Health Center food service program and providing the level of supervision necessary to ensure that courteous and efficient service is delivered as well as high quality and nutritious foods. Principle Duties: Essential Job Duties: 1. Assists in the planning, scheduling and supervising of Health Center dietary personnel; . 3. Assists in developing work assignments for all dietary personnel assigning specific jobs and spot-checking work to ensure standards are met; . 5. Maintains pertinent and appropriate records, reports, schedules and studies as required by local, state and federal regulations and otherwise requested . Other Job Duties: . Performs specific work duties and responsibilities as assigned by supervisor . The facility job description titled, Sous Chef, revision ,d+[DATE], indicated: Position Summary: The Sous Chef provides full-scope, hands on production cooking in a community Culinary Services Department. Is responsible for maintaining a superior level of quality service and cleanliness at all times. Essential Job Functions: 1. Exemplify at all times Community standards of cleanliness, sanitation and operational organization; 2. Exhibit leadership, and management standards with all Culinary Services staff; . General Job Functions: . 20. Accept assigned duties, instructions or correction in a cooperative manner, voicing concerns or disagreement in a professional manner through established chain of authority according to state procedures. 21. Perform incidental housekeeping and maintenance tasks as may arise during the course of regular duties, in order to maintain a clean, safe, pleasant environment for residents, visitors and staff. 22. Perform all other related duties as assigned in an effective, timely and professional manner . The facility job description titled, Cook, updated ,d+[DATE], indicated: .Other Duties: 1. Maintains assigned workstation in a safe and sanitary condition; . 4. Performs specific work duties and responsibilities as assigned by supervisor .

Based on dietary staff observations, dietary staff interviews and dietary document review, the facility failed to ensure staff competency in relationship to dietary staff position as evidence by dietary staff not 1) knowing how to test the quaternary (quat ammonium compounds designed to kill germs) sanitizer solution used to sanitize the kitchen countertops and sanitize the pots and pans in the manual three-compartment sink process (wash, rinse, and sanitize), 2) using the correct Cool Down Process for hot foods, 3) follow therapeutic diets when portion sizes were not plated correctly and meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed prior to being pureed, 4) serving pasteurized (heat treated to kill harmful bacteria such as salmonella) eggs, and 5) thawing meat according to the facility's policy/procedure. Failure to ensure comprehensive staff competency may result in practices associated with cross contamination, foodborne illness (comes from eating contaminated food) and providing meals that did not meet the nutritional needs of residents further compromising the resident's medical status. Findings: 1. During a concurrent observation and interview on 10/24/23 at 10: 40 a.m., Dietary Aide T, who was new, was washing the pots and pans using the three-compartment sink process (wash, rinse, and sanitize). Dietary Aide T stated he scrapped the dishes, washed, rinsed, sanitize, and let the pots and pans air dry. Dietary Aide T did not know anything about testing the water temp and quat sanitizer in the three-compartment sink process. During a concurrent observation and interview on 10/24/23 at 11:15 a.m., the Dietary Supervisor used the ph (potential of hydrogen: a measure of the acidity or alkalinity of a solution) test strips, which ranged from 0 to 6, to test the sanitizer solution located in the red sanitizer bucket. The sanitizer solution was used to sanitize all food contact surfaces and food contact equipment. The test strip read 4.5 to 5 ph, which the Dietary Supervisor stated was the same as 400 ppm (parts per million). The Dietary Supervisor stated the kitchen used a broad range quaternary (quat ammonium compound designed to kill germs) sanitizer solution to clean the countertops. The Dietary Supervisor stated the sanitizer buckets were changed every two hours and if the cook prepped meat, the cook changed the sanitizer bucket after cleaning the countertops. During an interview on 10/24/23 at 12:05 p.m. and 12:20 p.m., the Food and Beverage Manager was asked for the Sanitizer Test Logs for the sanitizer buckets and testing the sanitizer solution in the three-compartment sink process, but none were provided. When the Food and Beverage Manager was asked about the ph test strips used by the Dietary Supervisor to test the quat sanitizer solution, the Food and Beverage Manager stated he figured out the Dietary Supervisor used the wrong test strip. The Food and Beverage Manager tested the sanitizer solution in the red bucket using the quat test strips, which read 150 ppm. During a concurrent observation, interview, and dietary record review on 10/24/23 at 2:20 p.m., the Pot and Pan Test Strip/Sanitation Bucket Log, dated 10/23 and the Dish Machine Temperature Log, dated 10/23, both posted over the three-compartment sink indicated the ppm for the high temperature dishwasher and three-compartment sink sanitizer compartment read 400 ppm at breakfast, lunch and dinner 10/1/23 through 10/21/23. Dietary Aide S was asked why a quat solution was being tested in a high-temperature dishwasher (a high-temp dishwasher used a detergent and rinse aid, but no sanitizer solution). Dietary Aide S stated he was told to write 400 ppm on both the Pot and Pan Test Strip/Sanitation Bucket Log, and the Dish Machine Temperature Log. Dietary Aide S stated he had never tested the water in the dishwasher or the sanitizer compartment of the three-compartment sink process. Dietary Aide S stated he thought the company came every two weeks to test the dishwasher. The Wash cycle of the dishwasher read 140 degrees Fahrenheit and the Rinse cycle read 182 degrees Fahrenheit. During an interview on 10/24/23 at 2:28 p.m., the Dietary Manager stated she taught Dietary Aide S to open the dishwasher after the rinse cycle and test the ppm, first thing in the morning before the first batch of dirty breakfast dishes were washed. During an interview on 10/24/23 at 2:35 p.m., Dietary Aide S stated he was told to put 400 ppm on the Pot and Pan Test Strip/Sanitation Bucket Log and the Dish Machine Temperature Log. Dietary Aide S stated he was never trained to test either the dishwasher water or the sanitizer solution in the three-compartment sink process. Dietary Aide S stated he was trained by another dishwasher who no longer worked at the facility, and he was training the new dishwashers. During a concurrent observation and interview on 10/24/23 at 2:45 p.m., the Certified Dietary Manager (CDM) tested the sanitizer solution used to clean the Pantry countertops. The CDM used a quat test strip, which she held in the sanitizer solution for 10 seconds, per instructions. The CDM stated the test strip read 150 ppm because the facility used a broad range quaternary sanitizer solution, with a safe range from 150 to 400 ppm. The CDM stated she was overseen by the Food and Beverage Manager, who was not a CDM. The CDM stated the Food and Beverage Manager had restaurant experience, but no kitchen experience for a skilled nursing facility (SNF). The CDM stated the Pantry used a low temperature dishwasher so a chlorine sanitizer solution was used for the rinse cycle, which tested 50 ppm. The CDM stated she did not know why the kitchen dietary staff would be testing a high temperature dishwasher for the ppm, because a high temperature dishwasher used a super high temperature during the rinse cycle to sanitize the dishes, not a chemical. During an interview on 10/25/23 at 3:55 p.m., the Food and Beverage Manager stated the Dietary Manager was in charge of production systems of the kitchen and competencies of the kitchen staff. The Food and Beverage Manager stated the Pot and Pan Test Strip/Sanitation Bucket Log for the three-compartment sink process and the Dish Machine Temperature Log looked like the 400 ppm was just penciled in. The Food and Beverage Manager stated a high temperature dishwasher did not need the ppm tested . During a concurrent observation, interview, and dietary record review on 10/25/23 at 9:10 a.m., the Food and Beverage Manager stated the dietary staff were using the produce wash (A vegetable using wash cleaning product designed to aid in the removal process of dirt, wax and pesticides from fruit and vegetables before they are consumed) test strips to test the quat sanitizer solution. Over the three-compartment sink, there was a chart explaining what the water temperature should be for wash, rinse and sanitizer compartments as well as the quat sanitizing solution range needing to be from 150-400 ppm. The Food and Beverage Manager tested the sanitizer solution in the three-compartment sink sanitizer compartment, which tested 200 ppm, not the 400 ppm, which had been written on the Pot and Pan Test Strip/Sanitation Bucket Log every shift/daily. The sanitizer bucket near the handwash sink closest to the stove used to sanitize the kitchen countertops tested zero. The Food and Beverage Manager stated the AM dietary staff shift started at 5 a.m., so the sanitizer bucket may not have been changed since the start of the AM shift. During an interview on 10/26/23 at 9:50 a.m., Cook V did not know how many seconds the quaternary test strip had to be held in the sanitizer solution before checking the ppm. Cook V stated the sanitizer bucket was changed every four hours (Dietary Supervisor had stated every two hours) and the quat test strip should be held in the sanitizer solution for 30 seconds (Per the quat tests strip kit, the strip should be dipped in the sanitizing solution for ten seconds for an accurate reading). Cook V could not find the Quat test strips to test the sanitizer solution. Cook V looked in the holder near the three-compartment sink, but the holder was empty. During an interview on 10/26/23 at 3:30 p.m., the Food and Beverage Manager and Dietary Supervisor stated there were no logs for testing the quat sanitizing solution in the red buckets and the sanitizing compartment of the three-compartment sink process. Both stated there were no logs showing the ppm of the sanitizer solutions were tested regularly. The dietary document titled, Sanitizer Use Concentrations for Food Service and Food Production Facilities, revised 4/30/20, indicated: 1. The U.S. Food & Drug Administration Food Code 2017, states the following guidelines for sanitizing solutions . c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm or 150-400 ppm, Minimum Temperature: 75 degrees Fahrenheit, and Minimum Contact Time: 30 seconds . 4. Sanitation buckets must be established with appropriate sanitizing solution for quaternary solution, 150-400 ppm; or 200 ppm depending on the product used and manufacturer guidelines . 5. Sanitizing cloths should be placed in the sanitizing buckets to be used for sanitizing all work surfaces and equipment. 6. Dietary should change these buckets at least three (3) times a day and test with the appropriate litmus strips each time the solution is changed to ensure accurate levels of sanitizer . Reference: U.S. Food & Drug Administration Food Code 2017. The dietary document titled, Hydrion (QT-10) Quat Dispenser 0-400 PPM, (Instructions for use of using sanitizer test strips) obtained from (https://www.microessentiallab.com/) > Best [NAME] (https://www.microessentiallab.com/category/best-[NAME], indicated: Dip the strip into the sanitizing solution for 10 seconds, then instantly compare the resulting color with the enclosed color chart which matches concentrations of 0-100-200-300-400 ppm. Test solution should be between 65- and 75-degrees Fahrenheit. The dietary document titled, Clean Quick Broad Range Quaternary Sanitizer, (Product used by the dietary staff), indicated: This is an EPA-registered broad range, liquid quaternary sanitizer. It is EPA approved for food contact sanitizing from 150 to 400ppm . Task Areas: 3-compartment sink (sanitizer compartment), Smallware, Food preparation surfaces as part of wash/rinse/sanitize/air dry (W/R/S) process, All food contact surfaces as part of W/R/S process, and Food contact equipment and equipment parts as part of W/R/S process. 2. During an interview on 10/25/23 at 9:40 a.m., the Dietary Manager, who ran the food production systems of the kitchen, was asked about the cool down process for potato salad. The Dietary Manager stated after the potatoes were cooked, one would place the potatoes in the refrigerator for four hours, and the temperature of the potatoes should reach 45 degrees Fahrenheit. The Dietary Manager did not know the cool down process for hot foods. The hot food item needing to be cooled down should be placed covered in the refrigerator, cooled down to 70 degrees Fahrenheit or less within 2 hours and then cooled down to 41 degrees Fahrenheit or less within four hours. The facility Policy/Procedure titled, Cooling Monitor for Hazardous Foods, revised 5/20/20, indicated: Policy: Food handling rules for cooling hazardous foods should be used by Food and Nutrition or Dining Services department employees. Hazardous foods are defined as: Beans/Rice/Pasta, Bean Sprouts, Pies/Pastries, Eggs, Unpasteurized, Potatoes, Meats/Soy Protein/Drippings used for Sauces or Gravies, Cheese/Whipped Butter, Chicken/Shellfish, Dairy /Non-Dairy Agents, Cut-Leafy Greens and Tomatoes, Mayo Mixed Salads, Melons . 5. Using the Cooling Monitoring Form (FORM 406) or other designated form record emperature of food every hour. The food should be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours and cooled from 70 degrees Fahrenheit to 41 degrees Fahrenheit in an additional 4 hours . 3. During an observation on 10/25/23 10:55, Cook U pulled the pot roast out of the oven, checked the temperature, which read 165.2 degrees Fahrenheit and sliced the pot roast. Cook U then placed two slices of pot roast in the blender for the two residents on a pureed diet without weighing the meat before adding the gravy and thickener nor was the sliced meat weighed for the other types of therapeutic diets (Regular Diet, Easy to Chew Diet, and Soft and Bite Size Diet, and CCHO/NAS (Consistent Carbohydrate diet: helps keep blood sugar levels stable/No Added Salt). A review off the Daily Spreadsheet, dated 10/25/23, for the lunch menu, indicated residents on a regular portion size should have been served three ounces of the pot roast and residents on small portion size, should have been served two ounces of the pot roast. During an interview on 10/26/23 at 3:30 p.m., the Food and Beverage Manager and Dietary Supervisor did not know meat such as chicken, beef and pork, and fish needed to be weighed in order to know how many ounces the resident was plated per the therapeutic spread sheet. The Food and Beverage Manager and Dietary Supervisor stated they did not know about portion size per therapeutic spread sheets. The Food and Beverage Manager and Dietary Supervisor stated they did not weigh the meat (beef, pork chicken, turkey), and fish, to make sure the residents were receiving the correct portion size per the therapeutic spread sheet. 4. During the initial tour of the kitchen on 10/23/23 at 9:50 a.m., there were non-pasteurized eggs in the walk-in refrigerator, which were not covered and had no received by date. The Dietary Manager stated they used the Cage Liquid Eggs for the SNF. The Dietary Manager stated they normally have pasteurized eggs for the SNF. A review of a dietary document titled, Refrigerated Storage Quick Reference Guide, revised 1/9/2020, indicated: Eggs, in shell fresh: stored for 2-3 weeks, in the refrigerator at 35 to 41 degrees Fahrenheir or less, and keep small end down to center yolks. Stored in covered container. During a concurrent interview and dietary record review on 10/25/23 at 9:40 a.m., the October Dietary breakfast menu, dated 10/22/23-10/28/23, and the Always Available Menu for breakfast, indicated residents had a choice of style of eggs they wanted served (scrambled, omelets, sunny side up, or over easy). When the Dietary Manager was asked if there was any resident wanting a fried egg, she stated two residents had a fried egg this morning. The Dietary Manager stated the two residents wanted to substitute for a fried egg, so she honored their substitution even though she used non-pasteurized eggs. The Dietary Manager stated she has seen pasteurized eggs in the past, but the Food and Beverage Manager stated he has never seen pasteurized eggs and he did not know the SNF residents had to have pasteurized eggs. The facility Policy/Procedure titled, HCFA Clarification on Resident Rights and Food Safety, revised 8/31/18, indicated: The following is a question-and-answer clarification of resident rights and food safety for the Health Care Financing Administration. 16. F151-Fl77 483.10 Resident Rights . Potentially hazardous foods must be under continuous time and temperature controls in order to prevent either the rapid and progressive growth of infectious or toxigenic microorganisms, such as Salmonella found most often in poultry and eggs. Outbreaks of food borne illness involving eggs have been the result of improper refrigeration, cooking and holding temperatures . The facility Policy/Procedure titled, Egg Cookery and Storage, revised 5/20/2020, indicated: Policy: The Food and Nutrition or Dining Services department should ensure that eggs are prepared in a manner to preserve quality, maximize nutritional retention, and to be free of salmonella and acceptable to the resident. Procedure . 4. Do not use raw eggs as an ingredient in the preparation of uncooked, ready-to-eat menu items unless using pasteurized eggs. 5. Shell eggs must not be pooled. Pasteurized eggs should be substituted for shell eggs for such items as scrambled eggs, omelets, French toast, mousse, and meringue . 9. Pasteurized eggs in the shell may be cooked and served individually per resident's preference. 5. During an interview on 10/23/23 at 9:50 a.m., the Dietary Manager stated she would pull frozen meat out of the freezer on Friday so the meat could thaw in the refrigerator for three days (until Monday). If the meat was pulled from the freezer on Monday, the meat would thaw in the refrigerator until Thursday. The Dietary Manager stated the kitchen staff did not thaw by running water over the frozen meat. During a concurrent observation and interview on 10/26/23 at 3:30 p.m. three pork loins were placed in a plastic cylinder of water, located in the sink, and running water was flowing over the pork loins in order to thaw the pork loins. The pork loins were not submerged fully in the water per the thawing process. When it was pointed out to the Food and Beverage Manager the thawing pork loins was not completely submerge in the cylinder of water, he stated he did not realize meat had to be completely submerged in running water. The facility policy/procedure titled, Meat Cookery and Storage, revised 5/20/20, indicated: Policy: The Food and Nutrition Services Department should ensure that meat shall be prepared in a manner to preserve quality, maximize nutrient retention and to obtain maximum yield of product. Procedure . 2. Meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees Fahrenheit or less. Larger meats, such as whole turkeys may require additional thawing time. Date meat when pulled for defrosting During an interview on 10/25/23 at 10:15 a.m., the Registered Dietician (RD) stated the RD did monthly and quarterly audits of the kitchen, which showed the Food and Beverage Manager what needed to be corrected in the kitchen. The RD stated the Food and Beverage Manager was head of the entire Food/Beverage operations and he should know the SNF regulations. The CDM stated she has been down to the kitchen several times to provide input to the Food and Beverage Manager. The RD stated the Food and Beverage Manager was responsible for knowing the necessary food services of the SNF unit including food handling/process to prevent foodborne illness. The RD stated the Food and Beverage Manager should have known the residents on the SNF unit should only consume pasteurized eggs. The CDM stated she did inspections of the kitchen, made changes to the structure of the kitchen, explained to the cooks about the importance of following recipes and the therapeutic spread sheets, the cool down process, and the importance of maintaining logs for the sanitizer solution. The RD and the CDM stated residents should never be served non-pasteurized fried eggs because there could be harmful bacteria leading to residents becoming ill. During an interview on 10/26/23 at 10:15 a.m., the Food and Beverage Manager stated he oversaw all three areas of the facility, which included the SNF unit. The Food and Beverage Manager stated he had no background in the Food and Nutritional Services for SNFs. The Food and Beverage Manager stated this was why there is a CDM, who also does the Dietary in-services regarding the SNF Dietary Regulations and Title 22 (California Code of Regulations). The Food and Beverage Manager stated he knew nothing about kitchen staff competencies acknowledging the skills the dietary staff were supposed to be proficient in pertaining to their job description. The Food and Beverage Manager stated he understand the quat sanitizer solution needed to be checked per the test strip kit instructions to make sure the ppm was within the recommended range, so the kitchen countertops were sanitized sufficiently to prevent foodborne illness. During an interview on 10/26/23 at 11:53 a.m., the CDM stated there were no dietary staff competencies. The facility job description titled, Director of Food and Beverage Services, updated 7/2015, indicated: General Summary: The Director of Food and Beverage Services is responsible for the overall effective dietary services; selecting, training and supervising all dietary services personnel; procuring supplies and equipment; assisting with budget preparation and operating within budgetary guidelines. Principle Duties: Essential Job Duties: 1. Organizes, directs and supervises all dietary service functions in consultation with the Dietitian; 2. Maintains established dietary standards and policies and assists the Dietitian in establishing and revising dietary policies and procedure . 5. Prepares menus for distribution including processing diet changes, checking that menus for patients on special diets or with dietary restrictions comply with physicians' orders, identifying menus (normal diets and special diets) and planning meals accordingly; 6. Directs duties of Cook, etc. as required. Checks special diet trays . 8. Assures efficiency of food preparation and serving; compliance with local, state and federal standards; sanitation, and hygiene and health standards of personnel. 9. Oversees the selection, training, evaluating and disciplining of all dietary personnel. 10. Reviews and maintains required records and reports covering (a) number and kinds of regular and therapeutic diets, (b) prepared nutritional and caloric analyses of meals, costs of raw food and labor . Other Duties: . 5. Keeps appropriate records . 6. Monitors the care and the safe and sanitary use of supplies and equipment and all infection control policies and procedures . 8. Attends in-service training and education sessions as assigned . The facility job description titled, Dietary Manager, updated 7/2015, indicated: General Summary: The Health Center Dietary Manager is responsible for overseeing Health Center food service program and providing the level of supervision necessary to ensure that courteous and efficient service is delivered as well as high quality and nutritious foods. Principle Duties: Essential Job Duties: 1. Assists in the planning, scheduling and supervising of Health Center dietary personnel; 2. Assists in developing all menus for Health Center residents assessing preferences and nutritional needs. Assists in assuring staff education is provided to dietary personnel in accordance with the staff education plan plus provides on the job training for Health Center dietary personnel; 3. Assists in developing work assignments for all dietary personnel assigning specific jobs and spot checking work to ensure standards are met; 4. Assures that each resident's nutritional adequacy is met by utilizing the assurance of Nutritional Adequacy Policy; 5. Maintains pertinent and appropriate records, reports, schedules and studies as required by local, state and federal regulations and otherwise requested . The facility job description titled, Sous Chef, revision 8/2017, indicated: Position Summary: The Sous Chef provides full-scope, hands on production cooking in a community Culinary Services Department. Is responsible for maintaining a superior level of quality service and cleanliness at all times. Essential Job Functions: 1. Exemplify at all times Community standards of cleanliness, sanitation and operational organization; 2. Exhibit leadership, and management standards with all Culinary Services staff; 3. Responsible for adhering to food quality, appearance and presentation standards at all times; 4. Produce and serve menu cycle programs that are compliant with required Nutritional/Dietary criteria as required by local regulations and correctly prepare diets provided per Policy and Procedure; Exhibit cooking standards of speed, accuracy, and efficiency. 6. Demonstrate knowledge in all areas of cooking preparation and production . General Job Function: . Observe infection control procedures . The facility job description titled, Cook, updated 7/2014, indicated: . Principle Duties: Essential Job Duties: . 3. Prepares or directs the preparation of all food served, following standard recipes and special diet orders . Other Duties: 1. Maintains assigned workstation in a safe and sanitary condition .

Based on observation, interview, acute care record and facility record review, the facility failed to ensure that one resident (Resident 1), who entered the facility without pressure ulcers, did not develop pressure ulcers when Resident 1 developed two avoidable pressure ulcers. This failure resulted in Resident 1 developing [MEDICAL CONDITION] (bacterial infection of the inner layers of skin), delaying his discharge home, and not being able to reach his highest physical level of well-being. Findings: During a telephone interview on 9/20/16 at 9:01 a.m., Complainant X stated she had visited Resident 1 on 9/16/16 in the facility. Complainant X stated Resident 1 was supposed to be discharged home on[DATE]. Complainant X had noticed Resident 1's shoes were bloody, and upon removing the shoes, noted his feet were swollen, they smelled bad and his left heel was slimy green. Complainant X stated Resident 1's family had arrived, and had been aware only of a small blister to his right foot. Complainant X stated the head of nursing (Administrative Staff B) was asked to come to Resident 1's room. Administrative Staff B agreed that it was a bad ulcer, and stated she had not been aware of Resident 1's left heel ulcer. Complainant X and Resident 1's family had insisted on Resident 1's transfer to the acute care hospital for treatment of [REDACTED]. Resident 1's clinical record review of a document titled Admission Record revealed Resident 1's admitted to the facility as 8/18/16. The document revealed Resident 1 was a [AGE] year old male who was admitted with among others, [DIAGNOSES REDACTED]. Resident 1's [DIAGNOSES REDACTED]. A document titled Progress Notes dated 8/18/18, revealed This is a nursing admission note ., pt (patient) will be turned every two hours. Heels are soft and elevated . A document titled BD Nursing Admission Data Collection dated 8/19/2016 revealed in section 2 Skin Integrity Review no indication of pressure ulcers. A document titled Minimum Data Set (MDS) Resident Assessment and Care Screening (an assessment tool) dated as completed on 8/31/16, revealed in section M0510 the facility assessed Resident 1 as being at risk for developing pressure ulcers. Resident 1's Initial Care Plan provided by the facility on 10/14/16 dated Target Completion Date: 8/22/16 revealed in the category titled Focus (Name) (Resident 1) has an ADL (Activities of Daily Living) Self care performance Deficit r/t (related to) dementia, weakness, abnormalities of gait/mobility, pain, s/p (status/post) (after) fall, femur fracture (broken thigh bone), agitation. The interventions /tasks category revealed The resident requires SKIN inspection daily with care. Observe for redness, open areas, scratches, cuts, discoloration and report changes to the nurse. Resident 1's Initial Care Plan provided by the facility on 12/6/16 and dated Date Initiated 8/19/16 revealed under section titled Focus (Name) (Resident 1) has potential for pressure ulcer development r/t (related to) weakness, incontinence (lack of bladder control), [MEDICAL CONDITION] (kidney disease), limited mobility, activity intolerance, confusion. The section titled Goal revealed (Name) (Resident 1) will have intact skin, free of redness, blisters, discoloration by/through review date. The section titled Interventions/Tasks (interventions performed by staff to achieve the goals) did not include floating Resident 1's heels, or protecting Resident 1's heels with booties. The Care Plan did not address revisions to address Resident 1's behavior of rubbing his feet on the mattress. A Care Plan addressing Resident 1's actual impairment to skin integrity r/t (related to) laceration (cut) to forehead sustained in fall, s/p pinning to surgical site to left femur had the intervention listed Resident need heels floated. A document titled Care Plan Conference Summary signed by 5 facility staff and 3 members of Resident 1's family, dated 9/1/16, indicated under Topics discussed . Skin: Surgical incision L (left) Femur (thigh bone). There was no discussion of the fact Resident 1 was at risk for skin breakdown due to rubbing his heels on the mattress and removing interventions the facility put in place. A document titled Collaborative Care Review (a type of interdisciplinary review when team of staff members discuss resident concerns) dated 9/13/16 and signed by Administrative Staff B, revealed on page 9 of 11 in section J. Skin Integrity revealed a right heel stage 2 pressure ulcer which was in-house acquired. Administrative Staff B indicated the pressure ulcer was avoidable, and no other wounds were present. Resident 1's care plan was not updated. A document titled Progress Notes dated 9/14/16 signed by Licensed Staff D revealed Resident noted with the blister to left of heel that is already burst and PU (pressure ulcer) with eschar/necrotic to right outer lateral side of heel. Tx (treatment) applied as ordered. Heel is being floated. A document titled Progress Notes dated 9/15/16 signed by Licensed Staff E revealed Resident noted with the blister to left of heel that is already burst and PU (pressure ulcer) with eschar/necrotic to right outer lateral side of heel. Tx (treatment) applied as ordered. Heel is being floated. The documentation by Licensed Staff D on 9/14/16 and Licensed Staff E on 9/15/16 is identical. A document titled Progress Notes dated 9/16/16 at 14:26 when Complainant X and family members were in the facility was signed by Licensed Staff F. The Progress Notes revealed R(right) heel pressure ulcer- unstageable (unable to determine depth of wound) measures at 5.5 cms in length and 4 cms in width at distal end and 3 cms at the proximal end, deep purple dry, hard to touch necrotic (dead tissue) wound base, surrounded by 10 cms x 11 cms redness with swelling noted . L (left) heel has a 2 cms x 2 cms and 0 depth, deep purple in color wound bed, unstageable . Resident 1 was taken to the local acute care hospital on [DATE]. A local acute care hospital document titled Emergency Department Report dated September 16th, 2016 at 17:55 (5:55 p.m.) revealed The extremity exam reveal stage II to III decubiti involving the heel right greater than left with the right area approximately 3-4 cm with central Afshar (sic) (Eschar) and surrounding [DIAGNOSES REDACTED] (redness of the skin) to the dorsal lateral (outer side) foot and proximal (inner side) ankle. The left heel reveals similar appearing ulcer 0.5 cm squared Afshar (sic) (Eschar) in the center with surrounding of [DIAGNOSES REDACTED] surrounding (sic) . Antibiotic therapy initiated regarding likely [MEDICAL CONDITION] secondary infection involving the right heel ulcer. The document revealed as Primary Impression Decubitus ulcer to both feet. The document revealed as Additional Impressions: [MEDICAL CONDITION] of right heel. A document titled Progress Notes dated 9/16/16 at 11:41 p.m. signed by Licensed Staff G revealed Pt (patient) sent to hospital at 4 pm for evaluation of ulcers on both heels .Pt returned around 7:30 p.m Pt came back with dx (diagnosis) of decubitus ulcer (bed sores) of both feet . and [MEDICAL CONDITION] (bacterial infection of the inner layers of skin) of right heel .Family with patient and was not happy with his condition . During an interview on 12/6/16 at 2:55 p.m., Licensed Staff D stated she had taken care of Resident 1, and he had been admitted without pressure ulcers. Licensed Staff D stated Resident 1 had been rubbing his feet on the bed and developed blisters on both heels. Licensed Staff D stated staff had attempted to float (put a pillow under the lower leg to keep the heels off the bed) Resident 1's heels, but it had not been helpful at all due to Resident 1 being too restless and removing the pillow. Licensed Staff D stated staff had tried booties (foam heel/foot covers ) on Resident 1' s heels but Resident 1 had removed them as well. When asked if the facility had tried anything else, Licensed Staff D stated just floating the heels. Review of the facility policy titled BSL Skin and Wound Care Protocols/Guidelines dated revised 6/2015 provided by the facility on 12/6/16, revealed interventions to prevent heel pressure ulcers which were not mentioned on Resident 1's care plan or implemented. Interventions included 1. skin prep (wipe used to toughen skin) q (every) shift to heels, 2. minimize exposure to pressure (skin sealant q (every) day, offload heels i.e. pressure relieving boots such as pllows, Prevalon Boot or Waffle Boot, 3. monitor area for any evidence of infection ([DIAGNOSES REDACTED] (redness), warmth, pain, swelling, fever, drainage, and notify physician per protocol .

Based on observation, interview, and record review, the facility failed to identify as a hazard an unlocked gate that opened to a concrete stairwell of 9 steps. This failure contributed to a resident falling down the stairs and subsequently dying. Findings: On [DATE] the California Department of Public Health received an Entity Reported Incident and a complaint that Resident 1 had sustained an un-witnessed fall down 9 steps while in his wheelchair. The fall resulted in the resident being sent to the emergency room where he died . During an observation on [DATE] at 1 p.m., the unlocked gate was on a patio off the dining room of the skilled nursing unit of the facility. The gate opened to a concrete stairwell of 9 steps down to a landing. Steps continued from the landing to a lower patio. The gate had a large "Stop" sign across the front and a large key ring through the latch acting as a temporary lock. When the key ring acting as a temporary lock was removed from the latch, the gate opened toward the person opening the gate, not toward the stairs. Review of Resident 1's clinical record on [DATE] at 3:45 p.m., revealed that the resident was [AGE] years old. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS: a resident assessment tool) of [DATE] and the Care Area Assessment (CAA) notes reported the resident was alert, oriented, social, and forgetful. The resident was non ambulatory and required extensive assistance with activities of daily living. The resident enjoyed going outside and was able to propel himself in his wheelchair around the unit. During an interview on [DATE] at 2 p.m., Administrative Staff F reported that the resident was independent in his wheelchair and liked to go out onto the patio. Staff F reported the resident usually left his room and exited to the outside via a side door to the patio. Staff F reported that he had worked at the facility since [DATE] and that the gate had never been locked since he had been at the facility. Staff F reported that after the accident he had a bush removed from the left side of the gate, installed a large Stop sign across the front of the gate, and placed a large key ring through the latch to act as a temporary lock. Staff F stated he was not in the facility when the accident occurred. Staff F stated Resident 1 was in his room on [DATE] about 2:45 p.m.. Staff A visited with the resident briefly before she started her rounds. Staff B also visited briefly with the resident. When both staff left to complete their rounds, the resident left his room in his wheelchair and went to the patio through a side door. At approximately 3 p.m. two resident assistants from another unit heard a crash and a cry for help. Both assistants looked out their windows and saw the resident on the landing in the middle of the stairwell. One of the assistants radioed the charge nurse of Resident 1's unit with a walkie-talkie. The charge nurse, Staff C, responded to the scene. Staff F stated that Staff C reported to him that the resident was alert and talking. Staff C told Staff D who had also responded to the scene to call 911. Staff C stayed with the resident until the paramedics arrived. When the paramedics arrived, they contacted the fire department for assistance. Staff F reported the resident was taken to the emergency room . The resident died in the emergency room . During an interview on [DATE] at 2:30 p.m., Staff C reported that she regularly cared for Resident 1. Staff C reported that the week before the accident on [DATE] the resident was clear, oriented, and talkative. Staff C reported that the resident liked to be outside, but she never saw him approach the gate or attempt to open the gate. Staff C reported she never thought the resident needed a wander guard since he always went in and out of the building safely on his own. Staff C reported that on [DATE] at 2:45 p.m., she was in the charting room getting report from the day nurse when Staff D called her on the walkie-talkie to report that one of her residents had fallen down the stairwell. Staff D requested her assistance at the site. Staff C reported that when she got to the stairwell 3 female staff members from assisted living and one male staff member from the memory unit were attending Resident 1. Staff C reported that the staff told her they had heard a crash and a cry from the resident but did not see the resident open the gate or witness the resident fall down the stairs. Staff C reported that one of the female staff had taken the wheelchair off the resident, positioned him on his right side, and placed the wheelchair cushion under his head. Staff C reported she assessed the resident. He was alert and talking and able to tell her his daughter ' s name and the name of the president of the United States. There was no bleeding. Staff C reported she told Staff D to call 911. The paramedics arrived and called for the fire department. Staff C reported she observed the paramedics and firefighters turn the resident on his back and place him on the transport board. Staff C reported that when the response team placed the resident on the board, he yelled in pain and stopped talking. The resident was transported to the hospital. On [DATE] at 1 p.m., a review of Resident 1 ' s clinical record at the hospital emergency department indicated that the resident died in the emergency department on [DATE] at 5:13 p.m. On [DATE] at 4 p.m., a review of the Sonoma County Sheriff 's Office Coroner's Findings on the death of Resident 1 revealed that the cause of death was Atherosclerotic Cardiovascular Disease. The report listed the following significant condition: Blunt Force Pelvic Injuries. " Based on the known circumstances and cause of death as determined by a forensic pathologist the manner of death is Natural. " During a telephone interview on [DATE] at 2 p.m., the forensic pathologist stated that she could not state that Resident 1's fall was a direct proximate cause of his death. The forensic pathologist stated that she could state that if the fall had not occurred, it is unlikely that the resident would have died from his underlying atherosclerotic cardiovascular disease at the time that he did. She stated that it is possible that the trauma from the fall exacerbated the resident's underlying cardiovascular disease, but the fall itself is not responsible for his death. The forensic pathologist stated that the CT scan of the resident's head did not show any evidence of trauma or bleeding. There was no evidence of emboli or blood clots on autopsy. The fracture to the resident's right lateral sacrum and left femoral neck were survivable. The forensic pathologist stated that she was staying with atherosclerotic cardiovascular disease as cause of death. The California Department of Public Health, Licensing and Certification Program issued an "A" Citation for this deficient practice.