Every finding on record at Serenethos Care Center, LLC

Based on interviews and record review, the facility failed to ensure that when it hired a part-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services. Findings: During an interview on 6/17/25 at 10:01 a.m. with the Dietary Manager (DM), DM stated she was not the dietary supervisor for the facility. DM stated she covers for the sister facility, another building, but recently was orienting a new dietary supervisor who was on his way to the facility. During an interview on 6/17/25 at 10:24 a.m. with the Dietary Supervisor (DS), DS stated he was the DS. DS stated he worked at the facility as the Dietary Supervisor and Maintenance Director. DS stated his duties included checking the refrigerators and making sure supply of food items are done. DS provided a food handler certification. During an interview on 6/19/25 at 10:56 a.m. with Registered Dietician (RD), RD stated she worked part time. RD stated she worked on site at the facility once a month. During a review of the food handler certificate, titled ServeSafe, the certificate indicated national restaurant association certification. During an interview on 6/17/25 at 11:23 a.m. with the Administrator (Admin), Admin stated she will review with RD the type of certification required for DS position.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for one out of four sampled residents (Resident 23) when nursing staff administered 4% lidocaine patch to Resident 23's knees on two separate days, instead of to the back as prescribed by the physician. These failures resulted in two medication errors being identified out of 27 opportunities during an observation of medication administration leading to a medication error rate of 7.41%. These deficient practices had the potential to result Resident 23 not having pain relief. Findings: During review of Resident 23's admission Record, dated 6/19/25, the admission Record indicated Resident 23 was admitted in September 2021 with a diagnosis of heart failure (when the heart does not pump as well as it should) and osteoarthritis (a breakdown of cartilage in joints, leading to pain and stiffness) with current pathological fracture (break) of the vertebrae (spine.) During a medication pass observation on 6/17/25 at 11:49 a.m., with Registered Nurse (RN) 1, RN 1 administered a 4% lidocaine patch (A topical skin analgesic for pain relief) to Resident 23's left knee. During a medication pass observation on 6/18/25 at 9:15 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 administered a 4% lidocaine patch to Resident 23's right knee. During a review of Resident 23's Order Summary Report, dated 6/19/25, The Order Summary Report, indicated a physician's order to apply a lidocaine 4% patch to the lower back once daily for pain management. During an interview on 6/19/25 at 1:40 p.m. with the Nursing Supervisor (NS), NS stated the nurse must contact the physician before applying the lidocaine patch to a different location than prescribed, and the physician must change the order.

Based on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) assessment for one of one sampled residents (Resident 1) was completed and coded accurately. This failure to accurately code Resident 1's PASRR assessments placed Resident 1 at risk to not receive care and services appropriate to his needs. Findings: During a review of Resident 1's admission Record, dated 6/19/25, the admission Record indicated Resident 1 has a diagnosis of major depressive disorder (MDD, a mental condition with a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and an eating disorder. During a review of the facility's provided letter titled Department of Health Care Services (DHCS) from Clinical Assurance Division, PASRR Section, Unable to complete PASRR II, dated 2/23/23, indicated Resident 1 had a positive PASRR I and PASRR II was not completed as Resident 1 was isolated as a health or safety precaution. During a concurrent interview and record review on 6/29/25 at 12:30 p.m. with Minimum Data Set Coordinator (MDSC) 1, MDSC 1 stated their role is to complete and update the PASRR assessments in Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) for residents at the facility. When reviewing the Minimum Data Set, Section A, dated 4/29/23, under A1500 Preadmission Screening and Resident Review, MDSC 1 stated the form indicated Resident 1 is currently considered by the state PASRR II process to have a serious mental illness and or intellectual disability or a related condition. While reviewing the DHCS letter, MDSC 1 stated she had not seen this letter and believed the PASSR II assessment had been completed. MDSC 1 confirmed that a PASRR II was never completed as Resident 1 was on isolation precautions as indicated by the DHCS letter. During a concurrent interview and record review on 6/19/25 at 12:30 p.m. with MDSC 1, the record review of the Minimum Data Set, Section A dated 4/29/25 under A1500 Preadmission Screening and Resident Review, MDSC 1 stated the form indicates No that Resident 1 is not currently considered by the state Level II PASRR process to have a serious mental illness and or intellectual disability or a related condition. MDSC 1 stated a PASRR II had not been done for Resident 1 and that they should review the documents every year to update and correct them in the MDS system. During an interview on 6/20/25 at 9:20 a.m. with the Medical Director (MD), MD stated PASRR II screening was important to ensure residents receive the care, treatment, and services to help treat their illness. MD stated that he was not aware a PASRR II had never been completed for Resident 1, and stated the facility should be monitoring and tracking this information. MD stated that the facility should be reporting this information to the physician.

Based on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 32% medication error rate (See F759). Findings: During observations, interviews, and document reviews conducted on 5/7/24, regarding medication administration practices at a nursing home facility. The following is a summary of medication errors that were identified: The facility's policy requires healthcare providers to identify residents using at least two distinct identifiers before administering medications. However, LVN 1 did not follow this protocol for three residents, relying solely on memory for identification. Additionally, the policy mandates offering water or an acceptable liquid with oral medications, but LVN 1 failed to do so for Resident 30, leading to difficulties in swallowing the medications. Another medication error involved LVN 1 leaving medication unattended with a confused Resident 23, who then self-administered two pills without supervision, raising concerns about medication safety. LVN 1 also administered acetaminophen to Resident 23 routinely, despite it being prescribed as needed for pain relief. Both, LVN 1 and LVN 2 did not follow the manufacturer's instructions for administering insulin Lispro injections, as they did not hold the needle in place for the recommended five seconds after injection, potentially affecting proper insulin absorption and effectiveness. During an interview on 5/8/24 at 9:30 AM an interview was conducted with three members of the Quality Committee: the Acting Administrator, the Social Services Administrative Assistant, and the Nursing Supervisor. During this interview, it was noted that they had not identified any issues related to medication pass observations. Furthermore, they did not have any ongoing performance improvement projects specifically aimed at addressing medication errors. However, the Quality Committee members acknowledged the need for improvements in the medication administration process. They expressed concern over the survey results, which indicated a medication error rate of 32%. This statistic underscores the urgency of their commitment to enhancing the current procedures.

Based on observation, interview, and facility document review, the facility failed to maintain the dish machine in safe operating condition when the temperature did not reach 120 (degrees) Fahrenheit (F). This failure had the potential for food preparation and food service utensils placed in the dish machine to not become fully cleaned and sanitized before being used. Findings: During an observation on 5/7/24 at 8:50 a.m. with [NAME] 1, [NAME] 1 loaded items into the dish machine and ran the machine. The dish machine was put through the wash and rinse cycle continuously two times and the wash and rinse cycle indicated 100 F on the temperature dial. [NAME] 1 stated it was 100 F, not reaching 120 F. [NAME] 1 ran the dish machine again through the wash and rinse cycle and in the last cycle, it indicated 115 F on the dial. [NAME] 1 stated it was supposed to reach 120 F. During an observation on 5/8/24 at 9:40 a.m., Dietary Supervisor (DS) ran the dish machine three times. The thermometer indicated 118 F. DS stated it was should have reached a minimum of 120 F. During a concurrent observation and interview on 5/8/24 at 9:48 a.m. with Maintenance Supervisor (MS), MS did another run of the dish washing machine and was watching the thermometer. The thermometer indicated 118 F on the dial. MS ran the machine two more times. MS stated it was 117 F on the first run, went up to 118 F on the second run, and still 118 F showing on the temperature dial for the third run. During a concurrent observation and interview on 5/8/24 at 10:15 a.m. with RD, RD ran the dish machine through the wash and rinse cycles for 5 times. When writer watched the temperature gauge, it indicated it was not reaching 120 F and it reached a maximum of 118 F. RD stated the dish machine water temperature was between 116 F and 118 F. During a telephone interview on 5/8/24 at 10:19 a.m. with the service contractor (SC) that services the facility's dish machine, SC stated the brochure says 120 F minimum for the low temperature for the dish machine. SC stated he would send the manufacturer's instructions. During a review of the Dish Machine Temperature Log for May 2024, the log indicated the temperature for the wash cycle for breakfast on: 5/1/2024 was 116 F 5/2/2024 was 118 F 5/3/2024 was 119 F 5/4/2024 was 118 F 5/5/2024 was 119 F 5/7/2024 was 100 F and rinse cycle of 115 F 5/8/2024 was 100 F During a review of the information plate attached to the front of the dish machine, the information indicated, Wash Temperature 120 F minimum and Rinse Temperature 120 F. During a review of the directions on the Dish Machine Temperature Log, dated 2018, which is used for documenting dish machine temperatures for May 2024, the log indicated to use manufacturer's guidelines on the machine for the range of wash and rinse temperatures. During a review of the facility's policy and procedures (P&P) titled Dishwashing, dated 2018, the P&P indicated, The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations . If you cannot achieve this temperature, alert the dietetic supervisor, or cook who will alert the maintenance personnel and stop washing dishes . Low-temperature machine: If you do not have the manufacturer's recommendations, use the machine at a range of 120 degrees F to 140 degrees F.

Based on the observations and interviews conducted, it was concluded that the facility failed to provide pharmaceutical services to meet the needs of each resident. This conclusion was drawn due to the discovery of expired medications found in the medication storage areas. Expired medications can no longer be considered viable or safe to administer, and thus will not meet the needs of the residents who require effective and safe pharmaceutical care. Findings: During an observation on 5/7/24, several expired medications were found in the medication cart at 01:40 PM. The following expired medications were stored at room temperature and identified: *Insulin Lispro 100unit/ml for Resident 8 with an open date of 4/2/24 *Novolog pen 100unit/ml for Resident 8 with an opened date of 4/3/24 *Novolog 100unit/ml for Resident 17 with an opened date of 4/2/24 Based on stability studies insulin that had been opened and stored at room temperature can be stored up to 30 days. The above indicated that the open date exceeded 30 days. During an observation on 5/7/24 at 02:05 PM, revealed that there was expired refrigerated medication in the form of a Pfizer Covid Vaccine, which had an expiration date of 5/4/24. It is important to note that administering expired vaccines may result in reduced efficacy. During an observation on 5/7/24 at 2:05 PM in the medication room, an inspection of the E-kit containing injectables and antibiotics revealed several expired medications. It was noted that the Emergency Drug Kit Usage report indicated the E-kit had been opened, and a medication was last used on 1/24/24. The following expired medications were found inside the E-kit: Atropine 1mg/ml (expired: 4/24) Gentamycin 80mg/2ml (expired: 12/23) Naloxone 0.4mg/ml (expired: 2/24) Hydralazine HCL 20mg/ml (expired: 3/24) Haloperidol 5mg/ml Vial (expired: 4/24) GlucaGen Hypokit (expired: 3/31/24) Diphenhydramine Vial (expired: 4/24) Chlorpromazine Amp (expired: 12/23) Atrovent (expired: 1/24 and 3/24) The presence of multiple expired medications raises concerns regarding the facility's medication management practices and the potential risks to patient safety. It is imperative that all medications are regularly checked for expiration dates and replaced as needed to ensure that only safe and effective medications are available for use. During an interview conducted on 5/7/24 at 2:05 PM, Nursing Supervisor was questioned about the presence of numerous expired medications found in the facility. Nursing Supervisor was unable to provide a clear explanation for the expired medications and expressed that she intended to investigate the matter further to determine the underlying cause of this issue. Proper medication management is crucial to ensure patient safety, and it is important for the facility's staff to maintain awareness of medication expiration dates and take necessary actions to replace expired medications promptly.

Based on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, eight medication errors were observed out of twenty five opportunities for five of six residents, resulting in an error rate of 32%. Findings: A review on 5/7/24 of the facility policy titled Medication Administration General Guidelines. The policy indicates that during a medication pass, residents should be identified before administering medication using at least two distinct identifiers. These identifiers may include the resident's ID band, checking the photo attached to the medical record, or verifying the resident's ID with another nursing care center staff member. It is important to note that resident room numbers or physical locations should not be used as identifiers. In summary, the policy requires healthcare providers to confirm each resident's identity using two unique methods before administering medication, ensuring that the proper individuals receive their prescribed medications. During an observation on 5/7/24, between 8:45 AM and 9:00 AM, LVN 1 did not utilize the required minimum of two resident identifiers when administering medications to three residents (Resident 30, Resident 23, and Resident 7) during that time frame. To adhere to the facility's policy on medication administration, healthcare providers must identify residents using at least two distinct identifiers before administering medications. In this instance, LVN 1 did not follow the established guidelines, potentially compromising patient safety and medication accuracy. During an interview on 5/7/24 conducted at 11:45 PM, Licensed Vocational Nurse 1 (LVN 1) reported that her primary method of verifying a patient's identification before administering medication was relying on her memory. She added that she sometimes consults the patient's photo as a secondary measure to ensure proper identification. While relying on memory might work in some cases, it is not a foolproof method for patient identification, as it is prone to errors and lapses. A review of the nursing home facility's policy titled Medication Administration General Guidelines, it is stipulated that during medication administration, at least 4 ounces of water or an acceptable alternative liquid should be provided with oral medications. Exceptions to this standard amount may be considered if fluid restrictions apply or if product manufacturers specify different requirements. Adhering to these guidelines ensures that residents can comfortably and safely swallow their oral medications, promoting the effectiveness of prescribed treatments and maintaining overall resident well-being. During an observed medication pass on 5/7/24 at 8:40 AM,LVN 1 administered six different oral medications to Resident 30 without offering any water. Resident 30 took the medications and attempted to swallow them but experienced difficulty after a few minutes. Resident 30 then requested water from the nurse to assist in swallowing the pills, as it was evident that he was struggling with their mouth slightly open and having trouble ingesting the medications. To prevent such occurrences in the future, it is crucial that healthcare providers offer water when administering oral medications, especially when multiple pills are involved. Ensuring residents can swallow their medications comfortably and safely is essential for their overall well-being and medication efficacy. During an interview on 5/7/24 at 11:45 AM, Licensed Vocational Nurse 1 (LVN 1) stated that she did not provide water with medications for Resident 30. However, LVN 1 acknowledged the importance of offering water to residents when administering medications, as it aids in the swallowing process and helps prevent potential discomfort or complications. Recognizing the significance of providing liquids with oral medications is an essential aspect of ensuring proper medication administration and promoting patient safety. A review on 5/7/24 of the facility's policy titled Medication Administration General Guidelines, it is stated that during the medication pass, when a nurse administers medication, the resident must be closely observed to ensure the complete ingestion of the prescribed dose. This policy aims to guarantee the safe and effective administration of medications by monitoring residents throughout the process. Adherence to these guidelines is crucial for preventing medication errors and promoting resident well-being. During an observation on 5/7/24 at 10:33 AM, LVN 1 was administering medications to a Resident 23 who appeared visibly confused and was communicating incoherently. Despite Resident 23's state of confusion, the nurse left six pills in a medication cup at the bedside and proceeded to leave the area. Subsequently, Resident 23 independently took two out of the six pills and ingested them without any supervision from the nurse. Given Resident 23's apparent confusion and lack of supervision during medication administration, this incident raises concerns regarding medication safety and adherence to facility protocols. To ensure resident safety and proper medication management, it is essential for healthcare providers to directly observe and assist residents throughout the entire process of taking their prescribed medications, especially when cognitive impairment or confusion is present. During an interview conducted at 11:45 AM, Licensed Vocational Nurse 1 (LVN 1) admitted to leaving medications at the bedside of Resident 23 and walking away. LVN 1 acknowledged that this action was not appropriate and committed to improving her practice in the future. It is essential for healthcare providers to maintain patient safety by closely monitoring medication administration and avoiding situations that could lead to errors or misuse. A review of the clinical record on 5/7/24 for Resident 23, the attending physician had prescribed acetaminophen 650 mg every six hours to be administered on an as-needed basis for mild pain. This medication is typically used for the relief of mild to moderate pain or fever. The as needed instruction indicates that the resident should receive acetaminophen only when required, rather than on a scheduled or regular basis. It's important to follow the prescribing physician's instructions for administering acetaminophen and to monitor the resident's response to the medication to ensure its effectiveness and safety. During an observation at 8:47 AM, Licensed Vocational Nurse 1 (LVN 1) prepared acetaminophen 650 mg for Resident 23. LVN 1 mentioned that she administers acetaminophen to Resident 23 on a routine basis. However, during the medication administration, LVN 1 did not inquire about Resident 23's pain level or any pain-related symptoms. During an interview at 11:30 AM with LVN 1 said that she routinely gives the acetaminophen 650 mg routinely. She said that she did not ask Resident 23 if had pain. She also said that she did not think Resident 23 had any pain. LVN 1 acknowledged that she was giving the acetaminophen routinely instead of on a as needed basis as prescribed by the physician. According to the manufacturer's insert for Insulin Lispro, when administering a subcutaneous injection, it is essential to hold the needle in place for a minimum of five seconds. This step ensures that the insulin is appropriately distributed into the subcutaneous tissue, allowing for optimal absorption and effectiveness. Adhering to the manufacturer's instructions, as well as those of the healthcare provider, is crucial for the safe and effective administration of Insulin Lispro and other medications. During an observation on 5/7/24 at 11:30 AM, Licensed Vocational Nurse 1 (LVN 1) administered two units of Insulin Lispro to Resident 4 via subcutaneous injection. However, LVN 1 immediately removed the needle from the skin after delivering the injection, instead of holding it in place for at least 5 seconds, as recommended by the manufacturer's insert and standard injection protocol. By failing to hold the needle in place for the recommended duration, LVN 1 may have compromised the proper distribution and absorption of the insulin dose, potentially affecting its effectiveness and the resident's blood sugar control. During an interview on 5/7/24 conducted at 11:45 AM, Licensed Vocational Nurse 1 (LVN 1) confirmed that she did not hold the insulin syringe in place for the recommended five seconds during the subcutaneous injection. She admitted to immediately withdrawing the needle from the resident's skin after administering the insulin. During an observation on 5/7/24 at 3:40 PM, LVN 2 administered nine units of Lispro insulin to Resident 8 via subcutaneous injection. However, LVN 2 immediately removed the needle from the skin after delivering the injection, instead of holding it in place for at least five seconds as recommended by the manufacturer's insert. During an interview conducted on 5/7/24 at 4 PM, LVN 2 acknowledged that she had forgotten to hold the needle in after injecting the Lispro insulin into Resident 8. LVN 2 stated that she was aware of the recommended practice of holding the Lispro insulin needle in Resident 8 for a few seconds after injecting insulin, but had forgotten to do so in this instance.

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary manner when: 1. A trash can in the dishwashing area was left uncovered. 2. The microwave was not clean. 3. Two packs of unopened corn Tortilla and one pack of opened Tortilla with a few left in the plastic bag, had expired. 4. A half full bag of premium golden light brown sugar with no received date and still in its paper sack. 5. A half full bag of salt still in its paper sack. These failures had the potential to result in contamination of food causing food borne illness for 30 residents who received food from the kitchen out of a facility census of 31. Findings: 1. During a concurrent observation and interview on [DATE] at 9:20 a.m. with Registered Dietician (RD), in the dishwashing area of the kitchen close to the back door, there was an uncovered gray round trash can that was almost filled up with trash. No staff was observed in the vicinity using the trash can. RD confirmed the trash was supposed to be covered with a lid. According to the FDA (Food and Drug Administration) Food Code 2022, dated [DATE], Section ,d+[DATE].113 indicated Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled. During an interview on [DATE] at 9:45 a.m. with RD, RD stated the trash can should have been covered because they don't want to attract insects and pests. 2. During a concurrent observation and interview on [DATE] at 9:55 a.m. with RD, in the food preparation area of the kitchen, the microwave had black residue scattered inside it, on the inside walls of the microwave. Also, the interior part of the microwave door and the external control panel had a greasy residue. The microwave cover on top of the microwave was covered with a greasy residue. [NAME] 1 and RD confirmed that the microwave and the microwave cover were dirty. According to the FDA Food Code 2022, dated [DATE], Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. During a concurrent observation and interview on [DATE] at 10 a.m. with RD, on the shelf in the dry goods storage room, were two unopened tortillas in plastic bags, had a received date label of [DATE]. RD confirmed they have expired, stated they were only good for one month. Also, on the shelf was one bag of opened tortillas, with opened date of [DATE]. RD confirmed that it had expired and was good only for one week. During an interview on [DATE] at 9:45 a.m. with RD, RD stated they don't want to have expired products because they might have spoiled and to prevent food borne illness. During a review of the facility's policy and procedures (P&P) titled Storage of Food and Supplies, dated 2017, the P&P indicated, All food products will be used per the times specified on the package . No food will be kept longer than the expiration date on the product. During a review of the facility's Dry Goods Storage Guidelines, dated 2018, the Guidelines indicated, Tortillas, corn and flour, Unopened on Shelf - 1 month; Tortillas, corn and flour, Opened on Shelf - 1 week. 4. During an observation on [DATE] at 10:05 a.m. with RD, in the dry goods storage room, on the lower shelf, was a brown bag half full of premium golden light brown sugar still in its paper sack, with no received date and no opened date. RD stated they received date was torn off when it was opened. RD stated she does not know when they opened it. RD stated the sugar should be stored in a container. 5. During an observation on [DATE] at 10:05 am, next to the sugar was a bag half full of salt still in its paper sack, with a received and opened date. RD stated the salt should also be in a container. During an interview on [DATE] at 9:45 a.m. with RD, RD stated the sugar, and the salt should be in containers with tight fitting lids to ensure they stay longer. During a review of the facility's P&P titled Storage of Food and Supplies, dated 2017, the P&P indicated, Dry bulk foods (flour, sugar, .spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized .All food will be dated - month, day, year .

Based on observation, interview, and record review, the facility failed to ensure that staff followed the infection prevention and control policy and procedure (P&P) to prevent spread of infection for two of four sampled residents (Resident 30 and Resident 8) when: 1) The nebulization mask (a medical device used to deliver medication in the form of mist, which is inhaled into the lungs) of Resident 30 was not dated or labelled and left exposed in the bedside table drawer touching other personal items and the drawer surface with brownish dusty material. 2)The nebulization mask and CPAP mask (continuous positive airway pressure machine is used in the treatment of sleep apnea. This device delivers continuous pressurized air through tubing into a mask that is worn while sleeping) for Resident 8 was not dated or labelled and left exposed at the bedside table without protective covering, touching high touch surface area. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents. Findings: 1. During a record review of Resident 30's, Admission Record, printed on 5/9/24, the record indicated Resident 30 was originally admitted to facility in July 2023. During a concurrent observation and interview on 5/6/24, at 11:08 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 30's nebulization mask was observed. The nebulization mask was noted to be uncovered and left exposed in the first drawer of bedside table touching multiple other personal items including comb, toothbrush, tooth paste, spit tray, and the bottom of the drawer surface. The bottom surface of the drawer was noted with brownish dust. The mask was also noted to be undated and unlabeled. LVN 3 stated the nebulization mask should be kept covered in a plastic bag and should be dated and labeled. LVN 3 also stated bacteria can grow in the mask and the patient can inhale and get infection. 2.During a record review of Resident 8's, Admission Record, printed on 5/9/24, the record indicated Resident 8 was originally admitted to facility in April 2024. During a concurrent observation and interview on 5/6/24 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 8's nebulization mask and CPAP mask were observed. LVN 3 stated the nebulization mask is open and uncovered in the drawer of the nightstand with other resident belongings. LVN 1 stated the CPAP mask is left exposed on top of the bedside table exposed to air. LVN 3 also stated the CPAP mask and nebulization mask should be dated and labeled and should be stored in a plastic bag after use. LVN 3 also stated bacteria can grow in the mask and the patient can inhale and get infection. During an interview on 5/7/24 at 3:51 p.m. with Infection Preventionist (IP), IP stated after use, the nebulization mask should be cleaned and stored in a zip lock bag with date and room number. IP also stated for CPAP mask, it should be kept in the CPAP machine if that feature is available in the machine or kept protected in a plastic bag after use. IP also stated since it's being used every day in the nose, there is high risk for infection, bacteria can be accumulated and is a portal for bacteria and viruses and when residents wear it on nose, they are at risk for infection. During a review of facility's P&P titled, Administering Medication through a small volume, revised on October 2010, the P&P indicated, Steps in procedure .29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.30. Change equipment and tubing every seven days, or according to facility protocol. During a review of facility's P&P titled, Policies and Practices- Infection Control, revised on July 2014, the P&P indicated, Policy statement . This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.

Based on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 8 residents who occupied 4 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During an observation on 5/7/24 at 2:00 p.m., the following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area Capacity 1 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 5 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 6 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds 12 Resident room [ROOM NUMBER].17x11.17 sq.ft 158.28 sq.ft 2 beds During random observations of care and services from 5/6/24 to 5/9/24, there was sufficient space for the provision of care for the residents in rooms 1, 5, 6, and 12. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the four rooms. Granting of room size waiver recommended.

Based on observation and interview, the facility failed to ensure an effective pest control program when flies were observed in the kitchen. This failure had the potential to cause food borne illness. Findings: During two observations and concurrent interviews on 5/8/24 at 11:40 a.m. and 11:52 a.m. in the kitchen, two flies were observed flying around in the dry goods storage area; two flies were observed flying around in the food preparation and the dishwashing areas, close to the back door, there was one fly on the back door screen. RD confirmed there were five flies. RD stated it was their delivery day and they left the door open for delivery of food items. During an interview on 5/8/24 at 12:35 pm, RD stated there was no fly trap in the kitchen. During review of the facility's policy an procedures (P&P) titled Pest Control, dated 2008, the P&P indicated, our facility shall maintain an effective pest control program . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. According to FDA Food Code 2022, dated 1/18/2023, Section 6-202.13 indicated Insect Control Devices, Design, and Installation. Insect electrocution devices are considered supplemental to good sanitation practices in meeting the code requirement for controlling presence of flies and other insects in a food establishment.

Based on observation, interview, and record review, the facility failed to maintain a working wall clock for one of one sampled resident (Resident 19) in her room. This failure placed Resident 19 at risk for confusion and disorientation. Findings: During a record review of Resident 19's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Section C, dated 4/21/24, the record showed Resident 19's Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score was 9 out of 15 indicating her cognition was moderately impaired. During a concurrent observation and interview on 5/6/24 at 9:47 a.m. with Resident 19, the wall clock in Resident 19's room showed the time was 6:15. Resident 19 stated she doesn't look at the clock in the room because it was not working and instead, she would look at the clock in the lobby to know what the time is. Resident 19 also stated she goes to dialysis every Monday, Wednesday, and Friday at 12:00pm. During a concurrent observation and interview on 5/6/24 at 12:32 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the wall clock in Resident 19's room was wrong and showed the time was still 6:15. LVN 3 stated having a wrong clock inside Resident 19's room puts Resident 19 at risk for confusion of the time and day. LVN 3 stated she does not check the residents' rooms and surroundings when she makes her rounds in the morning. During an observation and interview on 5/8/24 at 10:51 a.m., with Resident 19, the wall clock in Resident 19's room was still not fixed and showed the time was 12:35. Resident 19 stated, It would be nice to have it fixed and have correct time instead of checking the clock in the lobby. During an interview on 5/8/24, at 3:31 p.m., with Director of Nursing (DON), DON stated it was important for residents to have a working clock so they can know the correct time. The DON stated having a wrong clock might get the residents confused when they see an incorrect time. During a concurrent observation and interview on 5/9/24 at 2:36 p.m., with Licensed Vocational Nurse 1 (LVN 1), the clock in Resident 19's room was still observed to be wrong. LVN 1 stated the wall clock in Resident 19's room was not working and showed the time was 1:34. LVN 1 stated having a clock that is not working in a resident's room is not okay.

Based on observation, interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 20 and Resident 18) received proper grooming including nailcare when: 1. Resident 20 had long fingernails with black matter underneath 2. Resident 18 with contractures had long sharp nails digging into palms. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromised physical and psychosocial wellbeing. Findings: 1. During a review of Resident 20's Admission Record, printed on 5/9/24, the Admission Record showed Resident 20 was admitted to the facility on [DATE]. During a record review of Resident 20's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/20/24, Resident 20's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 6 out of 15, which indicates impaired mental status. Review of section GG (Functional Abilities and Goal) indicated Resident 20 was dependent on staff for self-care including shower and personal hygiene. During a concurrent observation and interview on 5/6/24 at 10:52 a.m., Resident 20 was sitting outside his room in a wheelchair with long nails with black matter underneath. Resident 20 stated if someone can cut them for him, he would like that. Resident 20 also stated he likes it when his nails are kept clean. During an interview on 5/6/24, at 11:10 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated nails should be trimmed every week during showers. LVN 3 stated if nails are not trimmed there is a risk that a resident can scratch himself and get skin tear and the bacteria under the nails can cause infection. During an interview on 5/9/24, at 12:07 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 20 is needs total assistance with activities of daily living (ADLs, activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). RN 1 also stated if nails are long and dirty infection can happen and can cause health issues. During a review of Resident 20's Care Plan-Self-care deficit, dated 12/3/23, the care plan indicated to assist resident 20 in ADLs including bathing /showering. 2. During a review of Resident 18's Admission Record, printed on 5/9/24, the Admission Record showed Resident 18 was originally admitted to the facility in January 2019. The Admission record also indicated that Resident 18 has multiple medical diagnoses including cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a record review of Resident 18's MDS, dated [DATE], Resident 18's BIMS was 2 out of 15, which indicates severely impaired mental status. Review of section GG (Functional Abilities and Goal) indicated Resident 18 was dependent on staff for self-care including shower and personal hygiene. During an observation on 5/6/24, at 9:57 a.m., Resident 18 was observed. Resident 18 was noted to have right hand contracture and with long fingernails with black matter underneath digging into contracted palms. Resident 18 nodded with his head from left to right side indicating, no, when asked if he liked long sharp fingernails. During a concurrent interview and observation on 5/6/24 at 10:06 a.m. with Certified Nursing Assistant (CNA) 3, Resident 18's fingernails were observed. CNA 3 stated Resident 18 cannot cut his fingernails by himself and must be trimmed every week. CNA 3 stated nails should be kept clean and short. CNA 3 also stated Resident 18 can scratch himself and staff when holding on to staff's hands during care. During an interview on 5/9/24 at 12:07 p.m. with RN 1, RN 1 stated if nails are long and dirty infection can happen and can cause health issues. During a review of Resident 18's Care Plan-Self-care deficit, dated 7/19/22, the care plan indicated to assist resident 18 in ADLs including bathing /showering. During a review of the facility's undated Policy and Procedure (P&P) titled, Activities of Daily Living, Supporting, on March 2018, the P&P indicated, Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review the facility failed to act upon consultant pharmacist's recommendations for clarification of indication of use for trihexyphenidyl (a medicine that improves muscle control and reduces stiffness in Parkinson's disease and other conditions) for one of five sampled residents (Resident 12). This deficient practice resulted in Resident 12 receiving unnecessary medication without proper indication and had the potential to negatively impact the resident's well-being. Findings: During a review of Resident 12's Admission Record Report, printed on 5/9/24, the report indicated Resident 12 was admitted to the facility in March 2023. During a concurrent interview and record review on 5/9/24 at 12:55 p.m. with Registered Nurse (RN) 1, the Pharmacy Consultation Report for March 2024 and resident's current orders were reviewed. The Pharmacy Consultation Report, printed on 3/31/24, indicated the following comments: [Resident 12] is receiving trihexyphenidyl, since 3/3/23: for fall syndrome. The pharmacist recommendations read as: Please clarify the medical diagnosis/indication to support the use of this medication. Do update facility records [Physician order sheet, MAR and or ICD 10 code) to reflect this rationale for current use of this medication. Is this medication used for drug-induced extrapyramidal symptoms?. The recommendations have not been reviewed by physician as of 5/9/24. During a concurrent interview and record review with Pharmacy Consultant (PC) on 5/9/24 at 1:00 p.m., Residents 12's March 2024 Pharmacy recommendations were reviewed. PC stated they requested clarification for the use/indication for the use of trihexyphenidyl 5 mg tablet Q Day as it is being given for fall syndrome which is not the correct indication for the use of the medication. Pharmacy consultant stated facility has 30 days to act upon the recommendation from the date they received the recommendations from the pharmacy. PC also stated the lowest most effective dose for the resident should be used to minimize side effects. PC was unable to provide information on when the recommendations were sent to the facility. PC also stated she usually sends it at the end of the month or early next month. During a concurrent interview and record review with RN 1 on 5/9/24 at 2:22 p.m., Resident 12's Physician's Orders and Medication Administration Record were reviewed. The Physician Orders and MAR indicated Resident 12 was still receiving trihexyphenidyl 5 mg tablet Q Day at the original dose for fall syndrome. RN 1 was unable to find any documentation if facility acted upon pharmacy recommendations for Resident 12. RN 1 stated she does not think, fall syndrome is not an acceptable diagnosis for the use of the medication and wants the physician to look at it. RN 1 also stated it is important to have correct dosage, diagnosis, and correct medication otherwise it can be misleading. During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Regimen Review and Reporting, the P&P indicated The consultant pharmacist reviews the medication regimen of each resident at least monthly. Findings and recommendations are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion. 6. Resident Specific MRR recommendations and findings are documented and acted upon by the nursing care center and /or Physician 8. The consultant pharmacist and the nursing care center follows up on the recommendations to verify that appropriate action has been taken.

Based on observations, interviews, and record reviews, the facility failed to ensure an environment free of accident hazards when: 1. For 36 of 36 residents, the facility main entrance door was not securely closed to prevent unauthorized entrance or exit by residents or visitors. 2. For one of four sampled residents (Resident 1), the existing door alarm system did not alert staff to his unauthorized exit. These failures resulted in Resident 1 eloping on two occasions with minor scrapes and scratches sustained after the second elopement, and had the potential to result in elopements by other residents and access to residents by unauthorized visitors. Findings: During an observation on 2/13/23, at 11:45 a.m., the facility main entrance door was ajar several inches. There was no alarm heard when the door was fully opened. The door was allowed to passively close, but the door did not fully close, and the door remained ajar by several inches. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation for generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS, an assessment tool to guide care), dated 1/26/23, indicated Resident 1 had a score of seven on the Brief Interview for Mental Status exam. (BIMS, the Brief Interview for Mental Status is anassessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired. A score of zero to seven is an indication of severe impairment.) The MDS indicated Resident 1 required assistance from at least one person for transfer between surfaces, and locomotion on and off the unit, was unsteady transferring from surface to surface, and used a wheelchair for mobility. During an interview on 2/13/23, at 12:09 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was assigned to care for Resident 1 on the morning of 2/8/23. CNA 1 stated Resident 1 usually used a wheelchair, but she had seen him walk short distances without using any assistive device. CNA 1 stated at around 8:00 a.m. she had taken Resident 1, in his wheelchair, to the facility entrance near the nurses' station, and then left him there while she cared for another resident. When she returned, only Resident 1's wheelchair was still by the facility entrance, and Resident 1 could not be found inside the facility. Staff located Resident 1 a block away from the facility, and he was returned without incident. During a phone interview on 2/13/23, at 12:30 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 2/8/23 at around 8:15 a.m., she saw Resident 1 seated in a wheelchair at the facility entrance near the nurse's station. LVN 2 stated she had not heard the entrance door alarm anytime that morning. LVN 2 stated if she had heard an alarm it would have alerted her to Resident 1 leaving the facility. LVN 2 stated at around 8:30 a.m., CNA 1 told her Resident 1 had eloped. A review of Resident 1's care plan titled, The resident is an elopement risk, dated 2/8/23, indicated Resident 1 had impaired safety awareness and wandered aimlessly. The interventions to attain the goal of, resident not leaving the facility unattended included to monitor Resident 1 on a hourly basis. During a phone interview on 2/13/23, at 12:52 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was walking in the hallway at 8:30 p.m. and saw Resident 1 lying in bed in his room. LVN 3 stated at 9:15 p.m., a certified nursing assistant told her Resident 1 was no longer in his bed. LVN 3 stated she had not heard a door alarm that evening. LVN 3 stated the main entrance door was locked, but the back entry door was not locked to prevent exit, so Resident 1 likely left through the back entry door. LVN 3 stated facility staff were unable to locate Resident 1 inside the facility or in the immediate area, so staff called the police at 9:20 p.m. for assistance. LVN 3 stated the police located Resident 1 on 2/10/23, around 4:00 a.m. and took Resident 1 to an emergency department for medical evaluation. A record review of Resident 1's Interdisciplinary Team's (IDT) progress note, dated 2/10/23, at 3:22 p.m., indicated Resident 1 returned to the facility from the emergency department on 2/10/23, at 12:45 p.m. The IDT progress note indicated Resident 1 had minor injuries: scratches and abrasions (shallow scrapes) on the left cheek, left ear, left shoulder, left knuckles, left lower back and right shin. The IDT note indicated the door alarms would be checked by the maintenance department. During an interview on 2/13/23, at 1:11 p.m., with Maintenance supervisor (MS) and Environmental Services Supervisor (EVSS), MS stated on 2/10/23, the Director of Nursing told him the main entrance and back entry door had non-functioning alarms. EVSS stated he assisted MS checking the door alarms. EVSS stated the door alarms had been functional, but he and MS replaced the main entrance and back entry with louder alarms on the morning of 2/13/23. During an observation and interview on 2/13/23, at 1:45 p.m., with MS and EVSS, at the facility main entrance door, the door was closed. When the door was opened, an alarm sounded. The door was allowed to passively close, but the door did not fully close and the door remained ajar by several inches. The door was then fully opened from the ajar position, and no alarm sounded. MS stated the facility's main entrance door should automatically close by itself, but upon inspection of the door hinge, MS stated the hinge was misaligned and prevented the door from fully closing. MS stated the alarm would not function correctly unless the door was fully closed.

Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to: 1. Ensure the physician documented in Resident 1's medical record: the basis for Resident 1's transfer to the hospital, the specific resident needs that cannot be met in the facility, the facility's attempts to meet the needs, and the service available at the receiving provider to meet the need. 2. Provide Resident 1's discharge summary and comprehensive care plan goals to the receiving provider upon his transfer to the hospital. These failures had the potential to result in Resident 1 not receiving necessary care and services. Findings: 1. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation for generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS, an assessment tool to guide care), dated 1/26/23, indicated Resident 1 had a score of seven on the Brief Interview for Mental Status exam. (BIMS, the Brief Interview for Mental Status is anassessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired. A score of zero to seven is an indication of severe impairment.) During a concurrent interview and record review on 2/17/23, at 3:55 p.m., with Hospital Manager of Patient Relations (HMPR 1), Resident 1's Emergency Department Provider Triage Note, dated 2/10/23 at 6:31 p.m., was reviewed. HMPR 1 stated the ED Provider Triage Note indicated Resident 1 arrived at the ED on 2/10/23, at 3:49 p.m. During an interview on 2/15/23, at 11:40 a.m., with Resident 1's physician (MD 1), MD 1 stated he had not completed any documentation after being notified of Resident 1's transfer to hospital ED including reason for transfer, the specific resident needs the facility cannot provide, facility's attempts to meet Resident 1's needs, and services hospital ED had available for Resident 1's needs. 2. During a concurrent interview and record review on 2/13/23, at 2:30 p.m., with Assistant Director of Nursing (ADON), Resident 1's, Progress Notes, dated 2/10/23 at 3:15 p.m., was reviewed. The ADON stated the note indicated Resident 1's physician was notified of the transfer to the hospital emergency department (ED). During an interview on 2/15/23, at 11:05 a.m., with the ADON, the ADON stated MD 1 had not completed a discharge or transfer summary. During an interview on 2/15/23, at 11:40 a.m., with MD 1, MD 1 stated facility staff had called and told him Resident 1 was being transferred to the hospital non-emergently for evaluation. MD 1 stated he had not communicated with any of the hospital staff. MD 1 stated he had not completed a discharge or transfer summary after facility staff told him about Resident 1's transfer to the hospital ED. MD 1 stated he usually completed non-emergency transfer or discharge summaries a week after residents left the facility. During a concurrent interview and record review on 2/15/23, at 12:05 p.m., with Social Worker 1 (SW 1) and ADON, Resident 1's transfer packet (documents sent with Resident 1 when he was transferred to the hospital) was reviewed. Resident 1's transfer packet included: Resident 1's Transfer/Discharge Report, dated 2/10/23 at 2:52 p.m., Resident 1's Physician Orders for Life-Sustaining Treatment (POLST), dated 2/9/23,and Resident 1's Order Summary Report, dated 2/01/23. ADON stated the Transfer/Discharge Report indicated the chief complaint was transfer to Hospital ED for further evaluation, per MD order and was completed by the charge nurse. The transfer packet did not include information which indicated Resident 1's comprehensive care plan goals.

Based on interview, and record review, the facility failed to ensure the resident/resident representative for one of four sampled residents (Resident 1) received written notification before transfer to another facility and failed to provide a copy of the notification to the Ombudsman. The failure to provide written notice with the reason for transfer, effective date of transfer, destination for transfer, resident appeal rights and contact information for the Ombudsman, and the failure to send a copy of the notice to the Ombudsman resulted in emotional distress for Resident 1's Responsible Party (RRP 1) and had the potential to impede or prevent RRP 1 and the Ombudsman from exercising Resident 1's appeal rights. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation for generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS, an assessment tool to guide care), dated 1/26/23, indicated Resident 1 had a score of seven on the Brief Interview for Mental Status exam. (BIMS, the Brief Interview for Mental Status is anassessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired. A score of zero to seven is an indication of severe impairment.) A record review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST), dated 2/9/23, indicated Resident 1 was not self-responsible and had a Responsible Party (RRP1) to make healthcare decisions. During an interview on 2/13/23, at 1:54 p.m., with Resident 1's RRP 1, RRP 1 stated Resident 1 had designated her as the responsible party for healthcare decision making. RRP 1 stated on 2/10/23, in the afternoon, the facility called her and told her Resident 1 would be transferred to a hospital and requested she meet Resident 1 at the hospital. RRP 1 stated the facility did not tell her why he was transferred. RRP 1 stated she was upset and frustrated and did not know if Resident 1 was sick or if he was dying or what. RRP 1 stated she had not received written notice for Resident 1's transfer to the hospital. During a concurrent interview and record review on 2/17/23, at 3:55 p.m., with Hospital Manager of Patient Relations (HMPR 1), Resident 1's Emergency Department Provider Triage Note, dated 2/10/23 at 6:31 p.m., was reviewed. HMPR 1 stated the ED Provider Triage Note indicated Resident 1 arrived at the ED on 2/10/23, at 3:49 p.m. During a phone interview on 2/24/23, at 12:27 p.m., with Social Worker (SW 1), SW 1 stated facility practice had been to notify resident responsible parties of transfer by phone. SW 1 stated responsible parties did not receive written notice about resident transfers and did not know of a requirement for residents or responsible parties to receive written notice of transfer or discharge. SW 1 stated RRP 1 was not given written notice of Resident 1's transfer to hospital ED.

Based on observation, review of facility documents, and staff interviews, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. Multiple issues were observed including the Food and Nutrition Services Department did not have a system in place to ensure the appropriate texture of food was prepared and served; the Food and Nutrition Supervisory staff did not ensure food safety and sanitation; and the Food and Nutrition Supervisory staff did not ensure staff were competent in performing necessary tasks to ensure food safety including ensuring the correct strength of sanitizer used to sanitize food-contact surfaces, and calibrating thermometers. In addition, when the dietitian was not full-time, frequent consultation was not provided from the dietitian, when the dietitian was at the facility 1 day a month. The lack of full-time, competent oversight of food and nutrition staff placed 1 resident (Resident 34) at risk for aspirating (to breath in or inhale foreign objects into the lungs. Aspiration can happen during choking but can also be silent, meaning there is no outward sign) and/or choking (severe difficulty breathing because of constricted or obstructed throat or lack of air) on food, and placed 29 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), both of which had the potential for resulting in death, for a facility census of 35. An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on December 15, 2022, at 12:00 p.m., in the presence of Administrator 1 (ADM 1) for not having full-time, competent oversight in the Food and Nutrition department which left staff, who were not competent or with the skill sets to carry out to carry out necessary tasks within the department. An acceptable plan of action was provided by the Administrator 1 (ADM 1) on December 16, 2022, at 2:13 p.m. The actions to remove the immediate jeopardy situation included: a Registered Dietitian (RD 2) was hired to provide supervision to Food and Nutrition services staff starting in the afternoon on 12/15/22 and ending on 12/18/22; and a full-time Registered Dietitian (RD 3) with a background in food service was hired to oversee Food and Nutrition Services starting 12/19/22. When it was verified that RD 2 was on site on 12/16/22, and a Food Service Management Agreement was provided on 12/16/22 and signed by RD 3 and Administrator 2 (ADM 2) to start full time on 12/19/22; the IJ was removed on 12/16/22, at 12:13 p.m. while the surveyors were onsite. Findings: 1. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Review of the document titled Dietitian dated 2003, showed the primary purpose of the Registered Dietitian's position was to plan, organize and direct the overall operation of the Food Services Department to assure that quality nutritional services were being provided on a daily basis and that the food services department was maintained in a clean, safe, and sanitary manner. Review of the Food Service Management Agreement dated and signed by RD 1 on 1/2/18, showed RD 1's duties and responsibilities included in-service training for dietary personnel and other staff as required; Assistance to help insure that Federal and State regulations for the facility's dietary department were met. This service agreement also showed the consultation hours were for 3 to 5 hours a month and if addition time was necessary, an hourly rate would be charged. Review of the job description titled FNS [Food and Nutrition Services] Director dated 2018, showed the FNS Director had to have the ability to train staff on how to properly prepare and serve food, as well as how to keep the kitchen clean and sanitary. In addition, the FNS Director was responsible for providing staff with in-service training, and for the preparation and service of all food. Review of the Policy and Procedure titled Sanitation dated 2018 showed the FNS Director was responsible for instructing employees in the fundamentals of sanitation in food services and for training employees to use appropriate techniques. On 12/12/22 at 9 a.m., during the Initial Tour of the kitchen, an observation and concurrent interviews with Cook 1 and Dietary Aide 1 (DA 1) showed Cook 1 and DA 1 working in the kitchen. When Cook 1 and DA 1 were asked if there was a supervisor available, they stated they did not speak English. In an interview on 12/12/22 at 10 a.m., Registered Dietitian 1 (RD 1) entered the kitchen to introduce herself. She stated she just was at the facility 1 day per month. She stayed for a few minutes to talk to the surveyors then she said she had to leave the kitchen to do her other work. In an interview on 12/12/22 at 10:40 a.m., the Director of Food and Nutrition Services (DFNS) arrived at the facility. DFNS stated worked at the facility about 3 days a week. She said she also worked at another facility. She stated she trained Cook 1 and promoted her to a cook, and Dietary Aide 1 (DA 1) was new, he started 2 weeks ago. She stated they were very good workers. In an interview on 12/13/22 at 9:40 a.m., DFNS stated she normally came into the facility on Tuesdays and was not in the facility Thursday to Sunday. She said sometimes she came into the facility on Mondays. In an interview on 12/15/22 at 9:25 a.m., RD 1 stated her usual day when she was at the facility 1 day a month included an inspection of the kitchen, talking to residents about their food, and clinical tasks such as reviewing significant weight changes, completing initial assessments for new admissions as well as complete annual assessments for longer term residents. 2. The Food and Nutrition Services Supervisory staff did not ensure the correct texture of food was served. (An IJ was issued, Cross-reference F-800) Review of the document titled Admission Record showed Resident 34 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia pharyngoesophageal phase (difficulty or discomfort in swallowing when food passes into the esophagus [tube that runs from the throat to the stomach]), dysphagia oropharyngeal phase (swallowing difficulty occurring in the mouth and/or throat), malignant neoplasm of the esophagus (cancer of the esophagus), severe protein-calorie malnutrition (a condition expressed if the patient has two or more of the following characteristics: obvious significant loss of muscle; less than 50 percent of recommended nutritional intake for at least 2 weeks; bedridden or significantly reduced functional capacity; significant weight loss), and cachexia (a general state of ill health involving marked weight loss and muscle loss). Review of the MDS [Minimum Data Set; an assessment tool] dated 12/6/22, showed Resident 34 had a BIMS (Brief Interview for Mental Status; a screen used to assist with identifying a resident's current cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses]) of 11 (a BIMS score of 8-12 means moderately impaired). Review of the document from the hospital titled Discharge Instructions/Summary dated 12/4/22 showed the discharge diet for Resident 34 was full liquid diet. Review of the document titled Progress Notes dated 12/4/22, showed a hospital discharge note from a medical doctor. The note showed Resident 34 was in the hospital with malnutrition from chronic esophagitis (inflammation that damages the esophagus)/esophageal stricture (abnormal narrowing of the esophagus). He underwent endoscopy (a procedure that involves inserting a thin, flexible tube called and endoscope down the throat and into the esophagus) and was found to have a stricture and the esophagus was easy to bleed. Review of the documentation titled Order Summary Report dated 12/15/22, showed a diet order with a start date of 12/13/2022 and no end date for Full liquid diet, Full Liquid Texture, Nectar consistency Review of the document titled Nutritional Risk assessment dated [DATE], showed under the section D. Goal/Interventions the diet order Full Liquid, NTL [Nectar Thick Liquids]. Review of the facility document Diet Manual For Long Term Care and Residential Facilities 2020 signed by the RD on 11/17/21, showed the Full Liquid diet consisted of foods which are liquid or become liquid at body temperature and are easily digested. Examples of when this diet would be ordered showed residents experiencing extreme difficulty chewing and swallowing and for acutely ill residents. Foods for this diet include broth, strained soups, milk, milk drinks, commercial protein supplement drinks, cream, juices, coffee, tea, custard, gelatin, plain ice cream, plain yogurt, refined cereal such as farina and cream of rice A review of the Academy of Nutrition and Dietetics Nutrition Care Manual, thicker and harder food items require greater effort in oral processing and swallowing, and providing hard or complex-textured food to people with dysphagia has resulted in death (Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed 12/20/22). Review of a published article located in the National Institute of Health, National Library of Medicine, dysphagia is more prevalent in older adults and is a secondary condition associated with dementia (a group of thinking and social symptoms that interferes with daily functioning) and neck cancers, and many other neurological (conditions (medically defined conditions that affect the brain as well as the nerves found throughout the human body and the spinal cord). Negative complications may be aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed and results in swelling and infection of the lungs) caused by aspiration or sudden death caused by choking. The use of texture-modified foods can reduce aspiration and choking risks in patients with oropharyngeal dysphagia. (Wu XS, Miles A, Braakhuis A. Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis. Healthcare. 2020;8(4):579 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767351/#B11-healthcare-08-00579 accessed 12/20/22) On 12/13/22 an observation of tray line food service which began at 11:55 p.m., showed Cook 2 referred to a spreadsheet titled Winter Menus dated 12/13/22 as she plated food for residents' lunch. The spreadsheet showed what type of food and portion sizes to serve to Regular diets and therapeutic diets (a meal plan that controls the intake of certain foods or nutrients. It is part of a treatment of a medical condition and is prescribed by a physician. Texture modification is a type of therapeutic diet). The modified texture diets on the spreadsheet were Pureed (food mechanically altered to a smooth consistency and has the consistency of mashed potatoes), Mechanical Soft (soft foods and regular foods mechanically modified to a softer texture. Meats, raw vegetables, and fruits are chopped and or ground), and Dysphagia Mechanical (foods that are moist, soft-textured, and easily formed into a small, rounded mass [bolus] in the mouth). The spreadsheet showed the Regular diet for the lunch meal consisted of a cheese enchilada (an enchilada is a rolled tortilla with a filling such as meat or cheese and served with a chili sauce), refried beans, and Mexicalli rice. Cook 2 stated chicken enchiladas were being served instead of cheese enchiladas. The cooked foods ready to serve for lunch were in pans on a steam table. The enchiladas were in a large metal pan and the pan was full of rolled, stuffed, tortillas which contained melted cheese and sauce over the top. The melted cheese appeared dark and crispy around the edges. The Mexicalli rice was orange in color and had kernels of corn mixed in with the rice. The refried beans were lumpy, and thick in texture. Cook 2 plated a regular texture diet which consisted of a chicken enchilada, a scoop of rice, and refried beans and handed the plate to Diet Aide 1 (DA 1). DA 1 placed the plate with the Regular texture food, on a tray on a serving cart. On the tray, where DA 1 placed the Regular texture food, the tray ticket showed the tray was for Resident 34. The space on the tray ticket where diet orders were shown, was blank. In a concurrent interview with the Director of Food and Nutrition Services (DFNS), she stated Resident 34 was on a Full Liquid diet and handwrote Full Liquid on the tray ticket. She said the computer was not set up to print Full Liquid diet on the tray ticket, so it had to be written on the tray ticket manually. The Regular texture diet placed on Resident 34's tray was not changed after the tray ticket with handwritten Full Liquid was placed on the tray. An observation on 12/13/22 at 12:21 p.m., showed the cart containing Resident 34's tray left the kitchen and was handed off to nursing staff to serve. Certified Nursing Assistant 3 (CNA 3) served Resident 34's tray to him, and he began to eat the Regular textured food. The surveyor asked CNA 3 to stop the resident from eating until the diet could be clarified. The surveyor immediately asked Licensed Vocational Nurse 1 (LVN 1) who was in the hallway to check Resident 34's tray for accuracy. She stated it was incorrect and removed the food from the resident's room. She said the resident received a Regular tray instead of a Full Liquid tray. (Cross-reference F726) In an interview on 12/14/22 9:20 a.m., Resident 34 stated since he got back from the hospital staff always took away food that was served to him saying he could not have it. In an interview on 12/15/22 at 9:25 a.m., Registered Dietitian 1 (RD 1) stated to her knowledge, the DFNS posted the full liquid diet guidelines on a cabinet door in the kitchen for staff to refer to. She stated she did not know if the Food and Nutrition staff were trained on the Full Liquid diet. She said if an RD was not in the building when the diet was ordered, the DFNS should train the staff on the diet. Then she stated she, referring to herself, should have done a training with the Food and Nutrition Staff when she was there on Monday (12/12/22). The RD stated she did a Nutrition Risk Assessment for Resident 34 on 12/12/22. She stated he came into the facility from the hospital on a full liquid diet on 12/4/22. She recommended the resident continue a full liquid diet in her assessment in accordance with what the recommendation from the hospital discharge summary and the speech therapist, who did not order an upgraded diet. In a phone interview on 12/16/22 at 10:51 a.m., DFNS stated there was no documentation for training Food and Nutrition staff on preparing a Full Liquid diet prior to 12/13/22. She stated the guidelines from the Diet Manual for the Full Liquid diet were posted on the cabinet door in the kitchen and the Food and Nutrition staff were supposed to refer to that to know what to serve to Resident 34. Review of the document titled Speech Therapy SLP [Speech and Language Pathologist] Evaluation and Plan of Treatment dated 12/7/22, showed in the Assessment Summary, Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for: . aspiration. Under recommendations, the diet recommendation showed for solid food puree consistencies [food with a smooth texture so that chewing is not required. The food is held together with just enough structure and is slippery enough so it can be moved from the front of the mouth to the back and swallowed with minimal effort. In an interview on 12/16/22, at 11:41 a.m., the Speech and Language Pathologist (SLP) stated her swallow evaluation for Resident 34 showed he could tolerate a pureed diet. The SLP stated she did not recommend Resident 34's diet be upgraded from Full Liquid to Pureed because she was told the Gastroenterologist (Doctor who is trained to diagnose and treat problems in the gastrointestinal [GI; relating to the stomach and the intestines] tract and liver) wanted the resident to remain on a Full Liquid diet due to vomiting and until he could evaluate the Resident. As shown in an observation on 12/13/22 at 11:55 a.m. and 12:21 p.m., Resident 34 was served a Regular textured diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy) that was more complex in texture than the pureed diet (smooth texture food that chewing is not required. This texture is held together with just enough structure and is slippery enough so the food can be moved from the front of the mouth to the back and swallowed with minimal effort) and full liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature). 3. The Food and Nutrition Services Supervisory staff did not ensure food safety and sanitation: According to the 2017 Federal Food Code, Epidemiological (the branch of medicine which deals with finding the cause of diseases) outbreak (a sudden start of a disease in a community or geographical area) data repeatedly identify major risk factors related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness are improper holding temperatures, inadequate cooking, contaminated equipment, and poor personal hygiene. A. Review of the policy and procedure titled Thawing [the process of a frozen substance becoming soft or liquid as a result of warming up] of Meats dated 2018, showed similar meat items could be thawed together but different meats such as chicken and beef should never be thawed on the same tray. Also, a drip pan should be used under food being thawed so drippings did not contaminate other food. In addition, meat had to be stored on the bottom shelf, below prepared, ready-to-eat foods (food that will not be cooked or reheated before serving). According to the 2017 Federal Food Code, Time/Temperature Control for Safety (TCS) Food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism (an organism which is capable of causing disease) growth or toxin (a naturally occurring organic poison) formation. Examples of TCS foods include animal food that is raw or heat-treated; a plant food that is heat treated) shall be thawed under refrigeration that maintains the food temperature at 41 degrees Fahrenheit (F) or less, completely submerged under running water at a water temperature of 70 degrees F or below, or as part of the cooking process. In addition, in the Food Code Annex, it is stated that freezing prevents microbial growth (increased number of bacterial [bacteria is a large group of single-cell microorganisms. Some cause infections and disease in animals and humans] growth) in foods, but usually does not destroy all microorganisms (microscopic [cannot be seen by the human eye but can be seen under a microscope] organisms, especially a bacterium, virus, or fungus). Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins (a naturally occurring poison produced by organisms). Furthermore, the Annex shows separating foods in a ready-to-eat form from raw animal foods during storage is important to prevent them from becoming contaminated by pathogens (organisms causing disease to its host [an animal or plant on or in which an organism lives]) that may be present in or on the raw animal foods. Regarding the storage of different types of raw animal foods, food is required to be separated based on anticipated microbial load (the number and type of microorganisms contaminating an object or organism) and raw animal food type. Separating different types of raw animal foods from one another during storage will prevent cross-contamination from one to the other. The required separation is based on a succession of cooking temperatures, which are based on thermal destruction (destruction by heat) data and anticipated microbial load. For example, to prevent cross-contamination pork, which is required to be cooked to an internal temperature of 145 degrees F for 15 seconds, shall be stored above or away from raw poultry, which is required to be cooked to an internal temperature of 165 degrees F due to its considerably higher anticipated microbial load. In addition, raw animal foods having the same cooking temperature, such as pork and fish, shall be separated from one another during storage because of the potential for allergen cross-contamination (a substance causing an allergic reaction transferred from one object to another). In an interview on 12/13/22 at 10:33 a.m., Student 1 introduced himself and stated he just came from out of town to observe the kitchen and be mentored (trained) by DFNS. He said he graduated college and was waiting to take his test to become a Certified Dietary Manager (CDM) An observation on 12/14/22 at 8:15 a.m., showed a food delivery truck parked in the street and food being carried into the kitchen by a delivery person. In an interview and observation on 12/14/22 at 9:30 a.m., Student 1 was in the kitchen and stated DFNS was out sick today. Two other staff were in the kitchen, Cook 1 and Cook 2. An observation on 12/14/22 at 10 a.m., showed a package of frozen raw chicken, a package of frozen raw pork, and a 10-pound packaged frozen, cooked, pot roast sitting out at room temperature, on a countertop/food preparation area, where the coffee machine and food preparation sink was located. The frozen pork package was less than an inch from the coffee pots filled with coffee, and both the package of chicken and pork were less than 6 inches from packages of single-use cups. Cook 1, worked around the frozen meat when she poured coffee into cups. An observation on 12/14/22 at 10:35 a.m., showed the package of chicken and pork, that were stored on the countertop, were placed inside the reach-in refrigerator. Both packages of meat were in the same metal container. The packages of meat were very large compared to the size of the metal container, so the meat did not fit in the container fully and hung over the edge. The meat was directly next to the shelled eggs and containers of ready to eat food such as mustard and thickened water. On 12/14/22 at 10:40 a.m., an observation and concurrent interviews with Cook 1, Cook 2, and Student 1, showed the packaged pot roast was still stored on the countertop. Cook 2 stated the pot roast was for dinner that night. Cook 1 stated the meat, including the pork, the chicken, and the pot roast, was stored on the countertop since 8:15 or 8:30 a.m., when the food was delivered that morning. Because there was not a qualified supervisor staff to interview, the surveyor asked Student 1 if it was okay for the pot roast to be stored on the countertop, he stated the meat should be on a tray or a pan. Then the pot roast was placed in a pan on the countertop. An observation on 12/14/22 at 11:10 a.m., showed the pot roast was still stored on the countertop. There was liquid inside the bag with the pot roast and the surface of the meat was soft when pressed in with a finger. An observation and concurrent interviews with RD 1 and Cook 2 on 12/14/22 at 1:30 p.m., showed RD 1 was in the kitchen. The pot roast was no longer stored on the countertop. Cook 2 stated she put the pot roast in the refrigerator. The surveyor let RD 1 know the pot roast was observed on the countertop until 12:35 p.m. Then RD 1 stated the pot roast could not be served. On 12/15/22 at 8:29 a.m., an observation and interview with Student 1, showed the chicken and the pork were in the reach-in refrigerator. Student 1 confirmed that according to the menu, the chicken stored on the countertop yesterday (12/14/22) was going to be served for lunch today (12/15/22) and the pork stored on the countertop yesterday was going to be served for dinner today (12/15/22). In an interview on 12/15/22 at 9:25 a.m., RD 1 stated when meat was delivered it had to be put into the refrigerator or the freezer. If the meat was placed in the refrigerator, it needed to go into a non-leaking container on the bottom shelf. She stated chicken had to be thawed separately, in separate containers, from other meats. She also said the meat should not be stored next to eggs. She also stated no meat should be stored on a countertop. In an interview on 12/16/22 at 10:51 a.m., the DFNS stated pork, chicken or pot roast had to be defrosted in the refrigerator or under running water. After a food delivery, the meat had to be placed in the freezer right away. She stated all the staff knew how to put the food delivery away because everyone was trained. She also stated chicken needed to be separated from other meats if stored in the refrigerator but thought it was okay if chicken was stored directly next to eggs. B. Review of the policy and procedure titled Hand Washing Procedure dated 2018, showed examples of when to wash hands and showed after touching soiled utensils, and before and after touching food with hands. Review of the policy and procedure titled Glove Use Policy dated 2018, showed gloved hands are a food contact surface that can get contaminated or soiled. Disposable gloves are a single use and should be discarded after each use, especially before handling clean food items. Procedures showed to wash hands, then using clean, dry hands, place a glove on each hand. Wash hands when changing to a fresh pair. Gloves must never be used in place of handwashing. According to the 2017 Federal Food Code, the person in charge shall ensure that employees are effectively cleaning their hands, by routinely monitoring the employees' handwashing. In addition, food employees shall keep their hands clean. Hands are to be washed after engaging in activities that contaminate the hands, and before donning (putting on) gloves to initiate a task that involves working with food. To avoid recontaminating their hands, food employees may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink. Also, if used, single-use gloves shall be used for only one task such as working with ready-to-eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Food employees may not contact exposed, ready-to-eat food their bare hands, and food that is contaminated by food employees through contact with their hands, shall be discarded. In addition, employees must wash hands in a handwashing sink and not in a sink that is used for food preparation or warewashing. As explained in the Food Code Annex, an analysis of 816 reported outbreaks of infected worker-associated outbreaks from 1927-2006, the two most frequently reported risk factors associated with implicated workers was bare hand contact with food, and failure to properly wash hands. In addition, no bare hand contact with ready-to-eat food and proper handwashing and prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled utensils, etc., are control measures for contaminating food with bacteria, viruses, and parasites. Also, even though bare hands should never contact exposed, ready-to-eat food, thorough handwashing is important in keeping gloves or other utensils from becoming vehicles for transferring microbes to the food. Multiuse gloves (gloves that are used more than one time), especially when used repeatedly and soiled, can become breeding grounds for pathogens that could be transferred to food. It is important to avoid recontaminating hands by avoiding direct hand contact with heavily contaminated environmental sources, such as manually operated handwashing sink faucet and paper towel dispensers. This can be accomplished by obtaining a paper towel from its dispenser before the handwashing procedure, then, after handwashing, using the paper towel to operate the hand sink faucet handles. Facilities must be maintained in a condition that promotes handwashing and restricted for that use. Handwashing sinks can be a source of contamination if used for food preparation and warewashing. On 12/13/22 at 8:55 a.m., an observation showed DA 1 washed his hands in the handwashing sink. First, he turned the water on by lifting the manual faucet handle, then he washed his hands and turned the water off touching the faucet handle. Next, he touched the lever on the manual paper towel machine dispenser to dispense a paper towel. Last, he used his hand to open the cabinet door to throw away the paper towel located under the sink. Then DA 1 put on a pair of gloves and removed resident food trays from a rack on the clean side of the dish machine. On 12/13/22 at 10:32 a.m., an observation showed Cook 2 turned on the water at the handwashing sink using the manual faucet handle. She filled a large plastic pitcher with water from the faucet. She turned off the water using her hands. Then she filled the tray line water wells (a space where water is added and heated to keep pans of food warm when placed on top of the well) with the water from the pitcher. When she filled the wells, she handled the metal well lids. She repeated this process and to fill the plastic pitcher, she set the plastic pitcher inside the sink. Next Cook 2 filled a pan with water for cooking by turning on handwash sink faucet, then filled the pan with water, then turned the faucet off manually, and put the pan of water on the stove. On 12/13/22 at 11:45 a.m., an observation showed Cook 2 wore gloves. She opened the reach-in refrigerator by touching the handle with her gloved hands. She took out a bag of shredded cheese. With her gloved hand, she reached inside the bag of cheese and removed a handful of cheese. She put the cheese on a tortilla in a pan on the stovetop. She repeated this process for a second tortilla. Then she folded the tortillas and pressed on the tortillas with her gloved hands. Then she opened and closed the oven door by pulling the handle with her gloved hands and put oven mitts on over her gloves and opened the oven again. She removed pans from the oven and closed the oven door. Then she removed the oven mitts and left the gloves on. She removed the foil from the top of the pans that she removed from the oven. In an interview on 12/13/22 at 11:47 a.m., the DFNS stated the quesadillas (a dish consisting of a tortilla that is filled with primarily cheese) prepared by Cook 2 were for 2 residents (Residents 14 and 26) on a renal diet (a diet typically prescribed for someone with kidney disease). On 12/14/22 at 9:30 a.m., an observation showed Cook 2 used the handwashing sink to rinse off utensils she used while she prepared food. First, she touched the faucet handle to turn the faucet on. Then she rinsed a spatula. Next, she turned the faucet off using her hands. Then she continued to prepare food. In an interview on 12/15/22 at 9:25 a.m., RD 1 stated she did [TRUNCATED]

Based on observation, interview, and document review, the facility failed to provide a resident (Resident 34) a special dietary need as well as ensure Food and Nutrition Services had a system in place for preparing and serving the correct diet texture according to the physician's order when a regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and intended for people without chewing and swallowing issues) was prepared for a resident (Resident 34) with prescribed modified texture Full Liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature). This failure had the potential for one resident (Resident 34) who had documented diagnoses showing swallowing difficulty, out of a facility census of 35, to aspirate (to breathe in or inhale foreign objects into the lungs. Aspiration can happen during choking but can also be silent, meaning there is no outward sign) and/or choke (severe difficulty breathing because of constricted or obstructed throat or lack of air) on food which could have resulted in death. An Immediate Jeopardy (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment, or death) situation was declared on December 13, 2022, at 3:03 p.m., in the presence of the Director of Nursing (DON), for the facility not having a system in place to ensure the preparation of the correct physician prescribed food texture. This resulted in a Regular texture diet prepared and served to a resident (Resident 34) who had a physician prescribed Full Liquid diet, as well as diagnoses showing swallowing difficulty. An acceptable plan of action was provided by the Administrator 1 (ADM 1) on December 16, 2022, at 2:13 p.m. The actions to remove the immediate jeopardy situation included: a full-time Registered Dietitian (RD) with a background in food service was hired for the facility to oversee Food and Nutrition Services starting 12/19/22; RD 1 started in-service training to Food and Nutrition staff on duty regarding the preparation of a Full Liquid diet; an RD will check the tray ticket (a piece of paper placed on the residents' meal tray which shows the resident's name, room number, diet, allergies to food, food likes and dislikes) daily to ensure correct diet type, texture; the electronic medical record was revised to create an option to add Full Liquid diet to the tray ticket as well as other diets as needed that are not already in the system. When it was verified that a Food Service Management Agreement was signed by the new RD and Administrator 2 (ADM 2) to start full time on 12/19/22; the electronic medical record was updated to print a tray ticket with a Full Liquid diet when ordered; and the competency and skillset of Food and Nutrition Staff to prepare a full liquid diet was verified, the IJ was removed on 12/16/22 when surveyors were onsite. Findings: Review of the document titled Admission Record showed Resident 34 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia pharyngoesophageal phase (difficulty or discomfort in swallowing when food passes into the esophagus [tube that runs from the throat to the stomach]), dysphagia oropharyngeal phase (swallowing difficulty occurring in the mouth and/or throat), malignant neoplasm of the esophagus (cancer of the esophagus), severe protein-calorie malnutrition (a condition expressed if the patient has two or more of the following characteristics: obvious significant loss of muscle; less than 50 percent of recommended nutritional intake for at least 2 weeks; bedridden or significantly reduced functional capacity; significant weight loss), and cachexia (a general state of ill health involving marked weight loss and muscle loss). Review of the MDS [Minimum Data Set; an assessment tool] dated 12/6/22, showed Resident 34 had a BIMS (Brief Interview for Mental Status; a screen used to assist with identifying a resident's current cognition) of 11 (a BIMS score of 8-12 means moderately impaired). Review of the document from the hospital titled Discharge Instructions/Summary dated 12/4/22 showed the discharge diet for Resident 34 was full liquid diet. Review of the document titled Progress Notes dated 12/4/22, showed a hospital discharge note from a medical doctor. The note showed Resident 34 was in the hospital with malnutrition from chronic esophagitis (inflammation that damages the esophagus)/esophageal stricture (abnormal narrowing of the esophagus). He underwent endoscopy (a procedure that involves inserting a thin, flexible tube called an endoscope down the throat and into the esophagus) and was found to have a stricture and the esophagus was easy to bleed. Review of the documentation titled Order Summary Report dated 12/15/22, showed a diet order with a start date of 12/13/2022 and no end date for Full liquid diet, Full Liquid Texture, Nectar consistency (a liquid that is easily pourable and comparable to heavy syrup found in canned fruit). Review of the document titled Nutritional Risk assessment dated [DATE], showed under the section D. Goal/Interventions the diet order Full Liquid, NTL [Nectar Thick Liquids]. Review of the facility document Diet Manual For Long Term Care and Residential Facilities 2020 signed by the RD on 11/17/21, showed the Full Liquid diet consisted of foods which are liquid or become liquid at body temperature and are easily digested. Examples of when this diet would be ordered showed residents experiencing extreme difficulty chewing and swallowing and for acutely ill residents. Foods for this diet include broth, strained soups, milk, milk drinks, commercial protein supplement drinks, cream, juices, coffee, tea, custard, gelatin, plain ice cream, plain yogurt, refined cereal such as farina and cream of rice According to the Academy of Nutrition and Dietetics Nutrition Care Manual, thicker and harder food items require greater effort in oral processing and swallowing, and providing hard or complex-textured food to people with dysphagia has resulted in death (Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed 12/20/22). Review of a published article located in the National Institute of Health, National Library of Medicine, dysphagia is more prevalent in older adults and is a secondary condition associated with dementia and neck cancers, and many other neurological conditions (medically defined conditions that affect the brain as well as the nerves found throughout the human body and the spinal cord). Negative complications may be aspiration pneumonia caused by aspiration or sudden death caused by choking. The use of texture-modified foods can reduce aspiration and choking risks in patients with oropharyngeal dysphagia. (Wu XS, Miles A, Braakhuis A. Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis. Healthcare. 2020;8(4):579 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767351/#B11-healthcare-08-00579 accessed 12/20/22) On 12/13/22 an observation in the kitchen of tray line food service which began at 11:55 p.m., and concurrent interview with the Director of Food and Nutrition Services (DFNS), showed Cook 2 referred to a spreadsheet titled Winter Menus dated 12/13/22 as she plated food for residents' lunch. The spreadsheet showed what type of food and portion sizes to serve to Regular diets and therapeutic diets (a meal plan that controls the intake of certain foods or nutrients. It is part of a treatment of a medical condition and is prescribed by a physician. Texture modification is a type of therapeutic diet). The modified texture diets on the spreadsheet were Pureed (food mechanically altered to a smooth consistency and has the consistency of mashed potatoes), Mechanical Soft (soft foods and regular foods mechanically modified to a softer texture. Meats, raw vegetables, and fruits are chopped and or ground), and Dysphagia Mechanical (foods that are moist, soft-textured and easily formed into a small, rounded mass [bolus] in the mouth). The spreadsheet showed the Regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy) for the lunch meal consisted of a cheese enchilada (an enchilada is a rolled tortilla with a filling such as meat or cheese and served with a chili sauce), refried beans, and Mexicalli rice. Cook 2 stated chicken enchiladas were being served instead of cheese enchiladas. The cooked foods ready to serve for lunch were in pans on a steam table. The enchiladas were in a large metal pan and the pan was full of rolled, stuffed, tortillas which contained melted cheese and sauce over the top. The melted cheese appeared dark and crispy around the edges. The Mexicalli rice was orange in color and had kernels of corn mixed in with the rice. The refried beans were lumpy, and thick in texture. Cook 2 plated a regular texture diet which consisted of a chicken enchilada, a scoop of rice, and refried beans and handed the plate to Diet Aide 1 (DA 1). DA 1 placed the plate with the Regular texture food, on a tray on a serving cart. On the tray, where DA 1 placed the Regular texture food, the tray ticket showed the tray was for resident 34. The space on the tray ticket where diet orders were shown, was blank. In a concurrent interview with DFNS, she stated Resident 34 was on a Full Liquid diet and handwrote Full Liquid on the tray ticket. She said the computer was not set up to print Full Liquid diet on the tray ticket, so it had to be written on the tray ticket manually. The Regular texture diet placed on Resident 34's tray was not changed after the tray ticket with handwritten Full Liquid was placed on the tray. An observation and concurrent interview on 12/13/22 at 12:21 p.m., showed the cart containing Resident 34's tray left the kitchen and was handed off to nursing staff to serve. Certified Nursing Assistant 3 (CNA 3) served Resident 34's tray to him, and Resident 34 began to eat the Regular textured food. The surveyor asked CNA 3 to stop the resident from eating until the diet could be clarified. The surveyor immediately asked a LVN 1 who was in the hallway to check Resident 34's tray for accuracy. She stated it was incorrect and removed the food from the resident's room. She said the resident received a Regular tray instead of a Full Liquid tray. (Cross-reference F726) On 12/13/22 at 3:03 p.m., an IJ was called in the presence of the Director of Nursing (DON), for the facility not having a system in place to ensure the preparation of the correct physician prescribed food texture, which resulted in a Regular texture diet prepared and served to a resident (Resident 34) who had a physician prescribed Full Liquid diet, as well as diagnoses showing swallowing difficulty. In an interview on 12/14/22 9:20 a.m., Resident 34 stated since he got back from the hospital staff always took away food that was served to him saying he could not have it. In an interview on 12/15/22 at 9:25 a.m., Registered Dietitian 1 (RD 1) stated to her knowledge, the FNSD posted the full liquid diet guidelines on a cabinet door in the kitchen for staff to refer to. She stated she did not know if the Food and Nutrition staff were trained on the Full Liquid diet. She said if an RD was not in the building when the diet was ordered, the DFNS should train the staff on the diet. Then she stated she, referring to herself, should have done a training with the Food and Nutrition Staff when she was there on Monday (12/12/22). The RD stated she did a Nutrition Risk Assessment for resident 34 on 12/12/22. She stated he came into the facility from the hospital on a full liquid diet on 12/4/22. She recommended the resident continue a full liquid diet in her assessment in accordance with the recommendation from the hospital discharge summary and the speech therapist, who did not order an upgraded diet. In a phone interview on 12/16/22 at 10:51 a.m., DFNS stated there was no documentation for training Food and Nutrition staff on preparing a Full Liquid diet prior to 12/13/22. She stated the guidelines from the Diet Manual for the Full Liquid diet were posted on the cabinet door in the kitchen and the Food and Nutrition staff were supposed to refer to that to know what to serve to Resident 34. Review of the document titled Speech Therapy SLP [Speech and Language Pathologist; expert in helping people with speech impediments and/or swallowing disorders] Evaluation and Plan of Treatment dated 12/7/22, showed in the Assessment Summary, Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for: . aspiration. Under recommendations, the diet recommendation showed for solid food puree consistencies [smooth texture food that chewing is not required. This texture is held together with just enough structure and is slippery enough so the food can be moved from the front of the mouth to the back and swallowed with minimal effort]. In an interview on 12/16/22, at 11:41 a.m., the Speech and Language Pathologist (SLP) stated her swallow evaluation for Resident 34 showed he could tolerate the texture of a pureed diet. The SLP stated she did not recommend Resident 34's diet be upgraded from Full Liquid to Pureed because she was told the Gastroenterologist (Doctor who is trained to diagnose and treat problems in the gastrointestinal [GI; relating to the stomach and the intestines] tract and liver) wanted the resident to remain on a Full Liquid diet due to vomiting and until he could evaluate the Resident. As shown in an observation on 12/13/22 at 11:55 a.m. and 12:21 p.m., Resident 34 was served a Regular textured diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy) that was more complex in texture than the pureed diet (smooth texture food that chewing is not required. This texture is held together with just enough structure and is slippery enough so the food can be moved from the front of the mouth to the back and swallowed with minimal effort) and full liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature).

Based on observation, interview, and facility document review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when physician prescribed food texture was not verified before serving food to residents, and when Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for one resident (Resident 34) out of a facility census of 35, to aspirate (to breath in or inhale foreign objects into the lungs. Aspiration can happen during choking but can also be silent, meaning there is no outward sign) and/or choke (severe difficulty breathing because of constricted or obstructed throat or lack of air) on food which could have resulted in death, when he was served a Regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and is for people with no swallowing or chewing issues) instead of the physician prescribed modified texture Full Liquid diet (foods that are liquid and/or turn into a liquid when at room temperature and/or body temperature). An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on December 13, 2022, at 3:03 p.m., in the presence of the Director of Nursing (DON), for nursing not verifying diet textures against the physician orders before nursing aides served diets to residents and not ensuring nursing aide competency regarding diet textures, which resulted in a Regular texture diet served to a resident (Resident 34) who had a physician prescribed Full Liquid diet, as well as diagnoses showing swallowing difficulty. An acceptable plan of action was provided by the Administrator 1 (ADM 1) on December 16, 2022, at 2:13 p.m. The actions to remove the immediate jeopardy situation included: a licensed nurse will check every meal tray for accuracy at mealtime; a Registered Dietitian (RD) will conduct in-services regarding diet textures and how to read a tray ticket (a piece of paper placed on the residents' meal tray which shows the resident's name, room number, diet, allergies to food, food likes and dislikes) to Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs); the DON will in-service all nursing staff to check the resident meals being served to the tray ticket for every resident. The competency and skillsets of LNs and CNAs was verified regarding checking diet texture in accordance with the tray ticket and the IJ was removed on 12/16/22 when the surveyors were onsite. Findings: Review of the document titled Admission Record showed Resident 34 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia pharyngoesophageal phase (difficulty or discomfort in swallowing when food passes into the esophagus [tube that runs from the throat to the stomach]), dysphagia oropharyngeal phase (swallowing difficulty occurring in the mouth and/or throat), malignant neoplasm of the esophagus (cancer of the esophagus), severe protein-calorie malnutrition (a condition expressed if the patient has two or more of the following characteristics: obvious significant loss of muscle; less than 50 percent of recommended nutritional intake for at least 2 weeks; bedridden or significantly reduced functional capacity; significant weight loss), and cachexia (a general state of ill health involving marked weight loss and muscle loss). Review of the MDS [Minimum Data Set; an assessment tool] dated 12/6/22, showed Resident 34 had a BIMS [Brief Interview for Mental Status; a screen used to assist with identifying a resident's current cognition] of 11 (a BIMS score of 8-12 means moderately impaired). Review of the document from the hospital titled Discharge Instructions/Summary dated 12/4/22 showed the discharge diet for Resident 34 was full liquid diet. Review of the document titled Progress Notes dated 12/4/22, showed a hospital discharge note from a medical doctor. The note showed Resident 34 was in the hospital with malnutrition from chronic esophagitis (inflammation that damages the esophagus)/esophageal stricture (abnormal narrowing of the esophagus). He underwent endoscopy (a procedure that involves inserting a thin, flexible tube called and endoscope down the throat and into the esophagus) and was found to have a stricture and the esophagus was easy to bleed. Review of the documentation titled Order Summary Report dated 12/15/22, showed a diet order with a start date of 12/13/2022 and no end date for Full liquid diet, Full Liquid Texture, Nectar consistency Review of the document titled Nutritional Risk assessment dated [DATE], showed under the section D. Goal/Interventions the diet order Full Liquid, NTL [Nectar Thick Liquids]. Review of the policy and procedure dated 2001 and revised April 2007 showed Nursing staff shall check each food tray for the correct diet before serving the residents. According to the Academy of Nutrition and Dietetics Nutrition Care Manual, thicker and harder food items require greater effort in oral processing and swallowing, and providing hard or complex-textured food to people with dysphagia has resulted in death (Academy of Nutrition and Dietetics. Nutrition Care Manual. http://www.nutritioncaremanual.org. Accessed 12/20/22). Review of a published article located in the National Institute of Health, National Library of Medicine, showed dysphagia is more prevalent in older adults and is a secondary condition associated with dementia and neck cancers, and many other neurological conditions. Negative complications may be aspiration pneumonia caused by aspiration or sudden death caused by choking. The use of texture-modified foods can reduce aspiration and choking risks in patients with oropharyngeal dysphagia. (Wu XS, Miles A, Braakhuis A. Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis. Healthcare. 2020;8(4):579 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767351/#B11-healthcare-08-00579 accessed 12/20/22) On 12/13/22 at 12:21 p.m., observation and concurrent interviews with CNA 3 and Licensed Vocational Nurse 1 (LVN 1), showed carts holding resident meal trays left the kitchen. One cart was wheeled to the end of the hallway and CNA 3 served the meal trays from the cart to residents in their rooms. One tray on this cart was for Resident 34. The tray ticket showed diet order for this resident was Full Liquid. CNA 3 removed the tray from the cart and served the tray to the resident who was in his bed. CNA 3 removed the lid from the plate of food and set up the resident's drinks. The food on the resident's plate included a chicken enchilada (an enchilada is a rolled tortilla with a filling such as meat or cheese and served with a chili sauce) with melted cheese on top and the edges of the enchilada appeared it was cook well with brown, crispy edges; a scoop of rice mixed with pieces of corn; and refried beans. The surveyor asked CNA 3 if the texture of food was correct for this resident. CNA 3 stated yes, it was pureed food, so it was okay. The resident began to eat. The surveyor asked the CNA to stop the resident from eating until the diet could be clarified. The surveyor immediately asked a LVN 1 who was in the hallway to check Resident 34's tray for accuracy. She stated it was incorrect and removed the food from the resident's room. She said the resident received a Regular tray instead of a Full Liquid tray. She said it was not her job to check all resident trays for accuracy before they were served, and the CNAs were expected to check the trays. In an interview on 12/13/22 at 12:40 p.m., CNA 3 stated she did not know what a full liquid diet was. Review of the facility document Diet Manual For Long Term Care and Residential Facilities 2020 signed by the RD on 11/17/21, showed the Full Liquid diet consisted of foods which are liquid or become liquid at body temperature and are easily digested. Examples of when this diet would be ordered showed residents experiencing extreme difficulty chewing and swallowing and for acutely ill residents. Foods for this diet include broth, strained soups, milk, milk drinks, commercial protein supplement drinks, cream, juices, coffee, tea, custard, gelatin, plain ice cream, plain yogurt, refined cereal such as farina and cream of rice. On 12/13/22 at 3:03 p.m., an IJ was called for nursing not verifying correct diet textures against physician orders before CNAs served diets to residents and not ensuring CNA competency regarding diet textures. In an interview on 12/13/22 at 3:30 p.m., the DON stated she expected nursing staff to lift-up the lid on the plate and compare the texture of the food to the diet order on tray ticket to ensure the texture was correct. In an interview on 12/14/22 9:20 a.m., Resident 34 stated since he got back from the hospital staff always took away food that was served to him saying he could not have it. In an interview on 12/15/22 at 9:25 a.m., Registered Dietitian 1 (RD 1) stated she did a Nutrition Risk Assessment for resident 34 on 12/12/22. She stated he came into the facility from the hospital on a full liquid diet on 12/4/22. She recommended the resident continue a full liquid diet in her assessment in accordance with what the recommendation from the hospital discharge summary and the speech therapist, who did not order an upgraded diet. Review of the document titled Speech Therapy SLP (Speech and Language Pathologist) Evaluation and Plan of Treatment dated 12/7/22, showed in the Assessment Summary, Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for: . aspiration. Under recommendations, the diet recommendation showed for solid food puree consistencies. In an interview on 12/16/22, at 11:41 a.m., the Speech and Language Pathologist (SLP) stated her swallow evaluation for Resident 34 showed he could tolerate a pureed diet. She did not recommend Resident 34's diet be upgraded from Full Liquid to Pureed because she was told the Gastroenterologist (GI) wanted the resident to remain on a Full Liquid diet due to vomiting and until he could evaluate the Resident. As shown in an observation on 12/13/22 at 11:55 a.m. and 12:21 p.m., Resident 34 was served a Regular textured diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and is for people with no chewing or swallowing issues) that was more complex in texture than the pureed diet (smooth texture food that chewing is not required. This texture is held together with just enough structure and is slippery enough so the food can be moved from the front of the mouth to the back and swallowed with minimal effort) and full liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature).

Based on interview and record review, the facility failed to provide two staff members for supervision during use of a mechanical lift (an assistive device for lifting and transferring people from one surface to another) to prevent the fall of one (Resident 3) of two sampled residents at risk of falls. For Resident 3, the failure to provide two staff members during use of the mechanical lift resulted in a fall during transfer from bed to a shower chair, and caused a [MEDICAL CONDITION] tibia (broken bone in the leg between the ankle and knee). Findings: A review of the Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/23/18, reflected a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) score of three, an indication of severe impairment. The MDS also indicated Resident 3 required total assistance from two or more staff members for transfer from bed to chair. A review of the care plan titled, Activities of Daily Living, dated 11/21/16, showed Resident 3 was totally dependent on two staff members for transfer when using a mechanical lift. During a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 5/22/19 at 8:53 a.m., CNA 1 stated her assignment on 12/28/18 included care of Resident 3. CNA 1 stated when she attempted to transfer Resident 3 from his bed to a shower chair using the (mechanical) lift, the sling (a cloth harness used to hold the resident during transfer) ripped, and Resident 3 fell to the floor. CNA 1 stated Resident 3's left foot had hit the floor first during his fall. CNA 1 stated she had not received training on use of the mechanical lift, so she had routinely transferred residents by herself until after Resident 3's accident on 12/28/18. A review of progress notes by Licensed Vocational Nurse 1 (LVN 1) dated 12/28/18 at 1:28 p.m., reflected, Resident 3 had a fall incident while being transferred with the (mechanical) lift. This happened around 11:30 a.m. Noted to have a small abrasion on the right hip area. A review of the care plan, The resident has had an actual fall, dated 12/28/19, indicated Resident 3 had a fall on 12/28/18. The care plan interventions included, 1) Will remind staff to always have two person assist on all (mechanical) lift patient (sic), 2) staff to check the sling strap at all times prior on using it for tear/worn out and will inform the charged (sic) nurse or SW (social worker) if it needed to replaced (sic) . A review of progress notes by LVN 1 dated 1/5/19 at 2:40 p.m., reflected, .the (physician) was notified of bruising and discoloration noted on the left lower leg and c/o (complained of) pain when the leg is being moved. An X-ray (X-ray, a noninvasive medical test which uses [MEDICAL CONDITION] to produce images of bones inside the body.) was ordered A review of the X-Ray report dated 1/8/19, indicated Resident 3 received the X-ray on 1/8/19. The report indicated Resident 3 had a broken left lower leg near the knee, with the bone still in correct anatomical position. During an interview with the Assistant Administrator (AADM) on 5/21/19 at 2 p.m., AADM stated the facility hired CNA 1 on 12/10/18. AADM was unable to provide documentation the facility had trained CNA 1 on proper use of the mechanical lift before Resident 3's fall incident on 12/28/18. During an interview with the Director of Nursing (DON) on 5/21/19 at 11:16 a.m., DON confirmed Resident 3 fell and broke his leg when CNA 1 attempted a one person transfer with a mechanical lift on 12/28/18 at 11:30 a.m. DON stated the facility policy required a minimum of two staff members for use of the mechanical lift to transfer residents. DON was unable to provide documentation CNA 1 received training on the use of the mechanical lift between CNA 1's date of hire on 12/10/18, and Resident 3's fall incident on 12/28/18. A review of the (mechanical) lift manufacturer's, User Manual, copyright (YEAR), showed a manufacturer recommendation of, two assistants be used for all lifting preparation, transferring from and transferring to procedures. A review of the facility policy and procedure titled, Lifting Machine, Using Mechanical, revised (MONTH) (YEAR), indicated: 1. At least two nursing assistants are needed to safely move a resident with a mechanical lift. 2. Mechanical lifts may be used for tasks that require .b. Transferring a resident from bed to chair.