Every finding on record at Veterans Home of California - West los Angeles

Based on observation, interview and record review, the facility failed to provide appropriate denture care for 1 of 3 sampled residents (Resident 1) when nursing staff cleaned dentures marked with another person's name without identifying that the dentures did not belong to Resident 1, and the dental record documented that nursing staff had applied copious amounts of denture adhesive to make the dentures fit. This failure resulted in Resident 1 wearing another person's improperly fitting dentures for an undetermined period and placed Resident 1 at risk for oral discomfort, gum irritation, and impaired use of the denture.A review of Resident 1's face sheet (demographic data) indicated that Resident 1 was admitted to the facility with diagnoses including spastic hemiplegia affecting the right nondominant side (muscle stiffness and weakness affecting the right side of the body) and dysphagia, oropharyngeal phase (difficulty moving food, liquids, or medication from the mouth through the throat). During a review of Resident 1's Dental Hygiene note dated 7/20/26, the note indicated that Resident 1 presented with a full upper denture and lower partial denture. The dentures had heavy generalized plaque accumulation and were marked with another person's name. The note indicated that the dentures did not belong to Resident 1 and that the nursing unit was notified. During a review of Resident 1's Dentist Exam dated 7/20/26, the dentist documented that another person's name was present on Resident 1's full upper and lower partial dentures. The dentist further documented that nursing had applied copious amounts of denture adhesive to make the dentures fit. The dentist could not confirm when or where Resident 1's own dentures were lost. The dental office retained the dentures that did not belong to Resident 1, planned to schedule Resident 1 for impressions for replacement dentures, and indicated that dietary staff would be informed that Resident 1 no longer had dental appliances and might require a change in his food profile. During an interview on 8/3/26 at 11:53 a.m., the Dental Hygienist stated that she discovered during Resident 1's dental appointment on 7/20/26 that the full upper and lower partial dentures were marked with another person's name and did not belong to Resident 1. The Dental Hygienist stated that Resident 1's gums were swollen and that she notified nursing staff and the dentist. During an interview on 8/3/26 at 11:42 a.m., Supervisor Registered Nurse 1 stated that the facility did not know when or where Resident 1's dentures were lost. Supervisor Registered Nurse 1 stated that staff had not been trained to verify identifying information on residents' dentures and that nursing staff would be trained to check residents' names on dentures to prevent a similar occurrence. During an interview on 8/3/26 at 3:40 p.m., Certified Nurse Assistant 1 stated that she cleaned Resident 1's upper and lower dentures and observed a large amount of denture adhesive on them. Certified Nurse Assistant 1 acknowledged that she did not check the identifying name on the dentures to ensure that they belonged to Resident 1. During a concurrent observation and interview on 8/3/26 at 11:19 a.m., Resident 1 was not wearing dentures, and no dentures were present in his labeled denture container. Resident 1 stated that his dentures were lost.

Based on observation, interview, and record review, the facility failed to discard single dose containers of acetic acid 0.25% irrigation solution (sterile rinse solution used to prevent bacteria growth and to reduce calcium buildup) according to manufacturer's guidelines. The irrigation solution was prescribed for one of three sampled residents (Resident 1) for suprapubic catheter (inserted through abdomen into bladder to assist with urinary voiding) irrigation. This failure had the potential to result in increased risk of catheter-associated urinary tract infections (CAUTI- infection that happens when germs enter the urinary tract through a tube used to drain urine) for Resident 1. Findings:During a review of Resident 1's Face Sheet (demographics), the Face Sheet indicated Resident 1's diagnoses included neuromuscular dysfunction of bladder (condition where nerve muscle coordination disrupts urine storage or release).During a review of Resident 1's Physician Orders (PO), dated 6/18/25, the PO indicated to irrigate Resident 1's suprapubic catheter with 120 milliliters (ml) of acetic acid 0.25% irrigation solution three times daily [totals 360 ml daily] for urinary tract infection (UTI) prophylaxis (treatment for prevention of illness).During an observation on 7/14/26 at 12:13 p.m., in Resident 1's room, two partially used 500 ml bottles of acetic acid 0.25% irrigation solution were observed. The bottles manufacturer's label indicated Single-dose container and to Use only if solution is clear and container and seal are intact .During a review of [manufacturer's] package insert for the 0.25% acetic acid irrigation solution, dated August 2023, the package insert indicated, After opening container, the contents should be used promptly in order to minimize the possibility of bacterial growth. Discard unused portion of irrigating solution since it contains no preservative.During a concurrent observation and interview on 7/15/26 at 8:09 a.m., with the Supervising Registered Nurse (SRN) in Resident 1's room, the two partially used 500 ml bottles of acetic acid 0.25% irrigation solution were observed. The SRN confirmed the two bottles were unsealed and used. The SRN stated the acetic acid bottles should have been discarded immediately after each use.During an interview on 7/15/26 at 9:35 a.m., with the Pharmacist (Pharm), the Pharm stated if a solution was labeled as single use because it has no preservatives then it should have been discarded after each use. During an interview on 7/15/26 at 10:26 a.m., with Resident 1's Primary Physician (MD), the MD stated Resident 1 had a history of recurrent UTIs and was currently hospitalized and being treated for a UTI. The MD also stated Resident 1 was at an increased risk for UTIs because of his suprapubic catheter.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 9/26/25, the P&P indicated, Drugs shall be stored in a manner that will keep them safe, effective, and secure. The P&P further indicated, . Drugs shall be stored under the proper conditions. as determined by. the specifications of the manufacturer as well as applicable regulations.

Based on interview and record review, the facility failed to accommodate Resident 1's right to access services outside the facility when transportation for Resident 1's off campus medical appointment was not properly coordinated. This failure resulted in Resident 1 missing his physical therapy appointment and experiencing emotional distress related to feeling neglected and having unmet care needs.Findings:During a review of Resident 1's Face Sheet (demographics), dated 7/6/26, the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs), acromegaly and pituitary gigantism (disorder that causes body parts to become abnormally enlarged), and spinal stenosis (narrowing of the spine that can lead to is narrowed).During an interview on 7/2/26 at 10:38 a.m. with Resident 1, Resident 1 stated he had a standing appointment twice a week at an off-campus specialty clinic that provided physical therapy for people with spinal injuries like his. Resident 1 stated he had a pickup time scheduled at 10 a.m. with the facility's transportation service for his 11 a.m. appointment. Resident 1 stated Certified Nursing Assistant (CNA) 1 escorted him to the pickup location at around 9:45 a.m. When they got there, Automotive Equipment Operator (Driver) 1 told them he was the only driver and could not take Resident 1 to his off-campus appointment at the specialty clinic because he was only assigned to take the residents going for appointments within the local campus, referring to the other residents that were also waiting at the pick-up point. Resident 1 stated Driver 1 did not offer any alternative transportation options so CNA 1 escorted Resident 1 back to his room. Resident 1 stated how incredibly upset he was that no one notified him about no driver being available, so he filed an official complaint. Resident 1 stated, later that day, the Director of Nursing (DON) told him there was another driver, Driver 2, that was available to take him if he had just waited downstairs. Resident 1 stated that he went back upstairs because Driver 1 already told him there were no other drivers. In addition, Driver 2 never called to notify him that they were downstairs and available to take him. Resident 1 stated this was not the first time he missed an appointment because his transport was not arranged properly, and he felt neglected, like the facility did not want to take care of him.During a concurrent interview and record review on 7/2/26 at 4:23 p.m. with Driver 2, the facility provided document titled, Transportation Medical Appointments, dated 6/29/26, was reviewed. The document indicated Resident 1 had an off-campus appointment with a pick-up time scheduled at 10 a.m. and a hand-written notation indicating it was canceled. Driver 2 stated she wrote down canceled because Driver 1 told her Resident 1 went downstairs and went back up to his room. Driver 2 stated she did not call the unit and let them know she was available to take Resident 1 to his appointment and did not confirm with anyone that Resident 1's appointment was canceled. Driver 2 stated, We are not personal drivers, and we can't cater to just one resident.During an interview on 7/3/26 at 8:59 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 and CNA 1 told her there was no driver available to take Resident 1 to his appointment on 6/29/26, but she did not call to check whether there was a driver available or assist in coordinating transportation to his appointment.During an interview on 7/3/26 at 1 p.m. with Driver 1, Driver 1 stated he told Resident 1 and CNA 1 that he was the only driver on 6/29/26 and did not tell them another driver was coming because he did not know when the other driver was coming. Driver 1 stated that if there were only two drivers working and a resident has an off-campus appointment, usually one driver handled all the local transport while the other handled the off-campus appointment.During an interview on 7/6/26 at 9 a.m. with CNA 1, CNA 1 stated she was escorting Resident 1 to the pick-up location on 6/29/26 for his off-campus appointment. CNA 1 stated Driver 1 told them there was no driver available to take Resident 1 to his appointment, so CNA 1 escorted Resident 1 back to the unit. CNA 1 stated she was unaware Driver 2 was available as Driver 2 did not notify staff of her arrival to transport Resident 1. CNA 1 stated she and Resident 1 never told anyone to cancel the appointment and that other drivers would call the unit as a courtesy if Resident 1 was not downstairs at the scheduled pick-up time.During an interview on 7/6/26 at 10:49 a.m. with the General Services Manager (GM), the GM stated Driver 2 was supposed to take Resident 1 to his appointment, but if a resident isn't in the lobby or waiting in the front, the drivers don't call up to the unit to ask if the resident's still going. They assume the resident's not coming.During a review of Resident 1's Care Plan, dated 6/16/26, the Care Plan indicated a care plan in place for Resident 1's risk for emotional distress related to having no transportation to physical therapy appointments. The Care Plan indicated an intervention for nursing to coordinate with transportation staff regarding Resident 1's off-campus appointments.During a review of Resident 1's Clinical Notes - Social Worker, dated 6/29/26, the notes indicated, [Resident 1] appeared unhappy and resigned after hearing the news after he was informed that there was no driver available for him. The notes further indicated Resident 1 reported that missing his standing medical appointment made him feel like his care was being neglected by the facility and that the event made him feel like other residents' care was more important than [his] care.' During a review of the facility's policy and procedure (P&P) titled, Transportation Service, dated 4/16/2026, the P&P indicated, It is the policy of the [facility name] to provide safe and timely transportation to the Residents . The P&P further indicated, Driver will coordinate with Nursing staff if a passenger is not at the designated loading area on time for departure.

Based on observation, interview, and record review, the facility failed to ensure residents were free from exploitation and misappropriation of funds for two of three sampled residents (Resident 1 and Resident 2), when Certified Nurse Assistant (CNA) 1 and CNA 2 pursued inappropriate personal relationships, while on duty, with Resident 1 and 2 by accepting gifts of food and money and using their personal cell phones to call and text photos to the resident's personal cell phones and CNA 1 asking Resident 1 to get married. This failure had the potential to cause psychosocial and emotional harm and placed medically fragile and mentally vulnerable residents at risk for personal, monetary, and sexual exploitation.1. During a review of Resident 1's Face Sheet (Demographics), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (Irregular, rapid heartbeat) and end stage renal disease (final stage of kidney disease where kidneys fail permanently and can't filter waste).During an interview on 1/13/25 at 10:38 am with Standards Compliance Manager (SCM), the SCM stated that one of Resident 1's daughters called the facility and threatened to call the Federal Bureau of Investigations (FBI) and California Department of Public Health (CDPH) about Resident 1 getting married to a staff member. During an observation and interview on 1/13/25 at 2:52 pm in Resident 1's room, Resident 1 was observed sitting in a wheelchair, dressed and well groomed. Resident 1 mentioned that while he was watching TV in the common area, CNA 1 knelt in front of him and asked if he would marry her, to which Resident 1 replied, Sure, why not. CNA 1 then asked if Resident 1 was serious, and Resident 1 responded, As serious as you are. Resident 1 said that CNA 1 suggested setting a date and decided on December 29th. Resident 1stated he was ok to marry CNA 1, who also offered to move him into her house in [NAME]. Resident 1 stated that with the money saved from living at the facility, he would help CNA 1 pay rent and living expenses. Resident 1 also noted that, around Thanksgiving time last year, Resident 1 gave CNA 1 fifty dollars to buy a turkey, mashed potatoes, and sweet potatoes for Thanksgiving. During an interview on 1/14/26 at 10:30 am with CNA 1, CNA 1 stated that she began working for the facility at 11/3/25. CNA 1 stated she had received abuse training upon hire and continued abuse training through Relias (Computer Based Training). CNA 1 denied having an inappropriate relationship with Resident 1 and stated that they only have a working relationship. CNA 1 denied taking any money from Resident 1. CNA 1 denied asking Resident 1 to marry her. CNA 1 stated that having an inappropriate relationship with a resident could lead to residents being taken advantage of.During a review of Resident 1's record titled, Minimum Data Set (MDS) Section C (Cognitive [relating to or involving the process of thinking and reasoning]), dated 12/29/25, the MDS indicated that Resident 1's Brief Interview for Mental Status (BIMS) score was 11, a score of eight - 12 indicated moderate problems with thinking and memory.During a review of Resident 1's record titled Clinical Note Entry, Social Services, dated 12/18/25, the note indicated that the Social Worker (SW) met with Resident 1 and the resident told the SW that he was going to get married on December 29, 2025, to a nurse who proposed to him. The note indicated the SW asked Resident 1 if it could be a joke and Resident 1 told the SW it was serious. The note indicated that the conversation was reported to the ADM and Elder Abuse Coordinator and it was advised that no reporting to CDPH was necessary.During a review of Resident 1's record titled, Clinical Note Entry, Social Services, dated 12/23/25, the record indicated that the SW spoke to both CNA 1 and Resident 1 about their relationship and CNA 1 expressed to Resident 1, in the presence of the SW, that she was not interested in engaging in a romantic relationship with Resident 1. During an interview on 1/14/26 at 12:13 pm with the Social Worker (SW), the SW stated that the relationship between CNA 1 and Resident 1 was getting weird and that CNA 1 had given Resident 1 her personal phone number and was sending pictures of herself to Resident 1. The SW stated that sending pictures to the residents was not appropriate and against the facility's policy. The SW stated that Resident 1 was oriented to person, place, and time but that Resident 1 was not great at knowing the situation, as Resident 1 wanted to move into CNA 1's house. During an interview on 1/14/26 at 2:46 pm with the Director of Nursing (DON), the DON stated that Resident 1 gave CNA 1 fifty dollars. The DON stated she was unsure of what their policy states on receiving monetary gifts from the residents.During an interview on 01/14/26 at 3:12 pm with the Administrator (ADM), The ADM stated that all staff cannot receive gifts as individuals.During an interview on 01/27/26 at 9:32 am with the DON, the DON stated that Resident 1 had given the fifty dollars to CNA 1 on 11/27/25.During a review of the facility's policy and procedures (P&P) titled Professional Boundaries and Ethics, dated 11/13/2019, the P&P indicated, Employees are required to maintain professional relationships with Residents . Employees will set and maintain boundaries with Residents . An employee will not receive or accept, directly or indirectly, any gift including, but not limited to, money, meals . any services, or anything of value from Residents . An employee will not engage in any activity that could be, or may give a perception of, overfamiliarity . Employees will not discuss their personal affairs or share personal information (e.g. personal problems, work related conflicts, telephone numbers, email address, etc.) with Residents . Employees are prohibited from and expected to recognize that engaging in a sexual, romantic, and/or emotional relationship with a Resident, even a consensual relationship, is not consistent with the employee's duties and obligations . Violations of this policy may result in disciplinary action up to and including dismissal.During a review of the facility's policy and procedures (P&P) titled, Elder Abuse Prevention and Response, dated 6/17/2017, the P&P indicated . Financial abuse occurs when a person or entity does any of the following . Takes, conceals, appropriates, obtains, or retains, or assists in taking, concealing, appropriating, obtaining, or retaining, real or personal property of an elder or dependent adult by undue influence . No Resident will be subjected to mental, physical, financial sexual, or verbal abuse, neglect, corporal punishment, involuntary isolation/seclusion, or misappropriation of property . Employees will be trained through new employee orientation, annually, and as needed thereafter on issues related to abuse prohibition practices.2. During a review of Resident 2's Face Sheet (Demographics), the Face Sheet indicated that Resident 2 was admitted on [DATE] with diagnoses of Diabetes Mellitus (High blood sugar) with other specified complication and mild cognitive impairment (problems with thinking, learning, memory, judgement, or concentration, affecting daily function).During an observation on 1/14/26 at 10:08 am of Resident 2's room. Resident 2's room appeared clean and without clutter or tripping hazards. Resident 2 was not in his room and was at an appointment outside of the facility and unavailable for interview. During an interview on 1/14/26 at 10:51 am with Certified Nurse Assistant (CNA) 2, CNA 2 stated she had been employed with the facility since 11/3/25. CNA 2 indicated that she received abuse training at this facility upon hire, utilizing the Relias computer training program. CNA 2 first met Resident 2 around ten years ago and she invited him to dinner at her house, which he attended. CNA 2 stated that on 1/9/26, Resident 2 bought her a burger and fries which she accepted. CNA 2 stated she was unaware that she could not accept the burger and fries. CNA 2 stated she was removed from providing care on 1/9/26 and that the DON told her it was against facility policy to date or have a romantic relationship with a resident.During a review of Resident 2's record titled, Clinical Note Entry, Social Services, dated 1/9/26, the record indicated the SW approached Resident 2 to clarify his relationship with [CNA 2] and Resident 2 stated that they were friends. The note indicated that Resident 2 admitted to buying [CNA 2] a twenty dollar lunch. During an interview on 1/14/26 at 12:24 pm with the Social Worker (SW), The SW stated that Resident 2's daughter reported that she talked with Resident 2 about the CNA speaking to him on his personal cell phone and Resident 2 stated CNA 2 was talking a lot about money. The SW stated that Resident 2 subsequently changed his cell phone number. The SW stated that staff should neither give nor ask for money from residents and that personal cell phone interactions with residents are against facility policy. During an interview on 1/14/26 at 2:46 pm, the Director of Nursing (DON) stated that CNA 2 denied any prior personal relationship with Resident 2. The DON mentioned a gift from Resident 2 to CNA 2 that appeared to involve $20, either in cash or food. The DON stated she was unsure of what their policy states on receiving gifts from the residents. During an interview on 1/14/26 at 3:12 pm with the Administrator (ADM), the ADM stated that all staff cannot receive gifts from residents as individuals. During an interview on 1/27/26 at 9:30 am with the DON, the DON stated that she had a conversation with a supervisor and was told Resident 2 was romantically involved with CNA 2. During a review of the facility's policy and procedures (P&P) titled Professional Boundaries and Ethics, dated 11/13/2019, the P&P indicated, Employees are required to maintain professional relationships with Residents . Employees will set and maintain boundaries with Residents . An employee will not receive or accept, directly or indirectly, any gift including, but not limited to, money, meals . any services, or anything of value from Residents . An employee will not engage in any activity that could be, or may give a perception of, overfamiliarity . Employees will not discuss their personal affairs or share personal information (e.g. personal problems, work related conflicts, telephone numbers, email address, etc.) with Residents . Employees are prohibited from and expected to recognize that engaging in a sexual, romantic, and/or emotional relationship with a Resident, even a consensual relationship, is not consistent with the employee's duties and obligations . Violations of this policy may result in disciplinary action up to and including dismissal.During a review of the facility's policy and procedures (P&P) titled, Elder Abuse Prevention and Response, dated 6/17/2017, the P&P indicated . Financial abuse occurs when a person or entity does any of the following . Takes, conceals, appropriates, obtains, or retains, or assists in taking, concealing, appropriating, obtaining, or retaining, real or personal property of an elder or dependent adult by undue influence . No Resident will be subjected to mental, physical, financial sexual, or verbal abuse, neglect, corporal punishment, involuntary isolation/seclusion, or misappropriation of property . Employees will be trained through new employee orientation, annually, and as needed thereafter on issues related to abuse prohibition practices.

Based on interview and record review, the facility failed to meet the minimum requirements for the Quality Assurance Performance Improvement (QAPI) committee meetings for three out of four quarters in 2025 when a Medical Director/Chief Medical Officer or qualified designee did not attend. This failure had the potential to diminish oversight in developing, reviewing, and approving crucial clinical policies that affected a medically fragile population of 142 residents since May 3, 2025.During a review of the QAPI meeting minutes, on 12/12/2025 at 08:30 a.m., dated 2/13/2025 through 11/13/2025, the attendance sheet indicated that the Medical Director/Chief Medical Officer or an official qualified physician designee did not attend meetings for the months of May, June, July, August, September, October, and November.During a concurrent interview and record review on 12/9/2025 at 12:47 p.m. with the Standards and Compliance Manager (SCM), The Facility Assessment, dated 2025-2026, was reviewed. The assessment indicated under the Staffing Section that there were 0 Medical Directors and 1 vacancy. The SCM confirmed that the Medical Director/Chief Medical Officer position was being temporarily filled by MD 1. During an interview on 12/11/2025 at 4:47 p.m. with Medial Doctor 1(MD1), MD1 indicated that the facility was currently without a Medical Director/Chief Medical Officer, and he was not responsible for the duties of the Medical Director/Chief Medical Officer. MD 1 stated that his position was as a staff physician with no oversight of medical staff or administrative duties. During an interview on 12/11/2025 at 5:06 p.m. with Administrator 1(Admin 1), Admin 1 indicated that the Medical Director/Chief Medical Officer position has been vacant since April 2025. During an interview on 12/12/2025 at 12:44 p.m. with Nurse Practitioner 1(NP1), NP1 indicated that she was not officially designated to the QAPI committee by the Medical Director/Chief Medical Officer because there was currently no facility Medical Director/Chief Medical Officer. NP1 further stated that she did not have a designated physician supervisor or Medical Director/Chief Medical Officer to whom she reported. During a review of the Quality Assurance & Performance Improvement (QAPI) Plan for Veterans Home of California - [NAME] Los Angeles 2025/2026 (Plan) on 12/12/2025 at 8:30 a.m., The Plan stated, The QAPI Committee, which includes the Chief Medical Officer, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were competent and adequately trained to safely carry out food services when: Multiple kitchen staff were not trained to intervene or discard hot food items that did not reach 70 degrees Fahrenheit ( F, unit of measurement for temperature) within two hours of the cooling process for potentially hazardous foods.The Food Service Technician (FST) did not receive training on the proper operation of the dishwasher.These failures had the potential to result in the spread of food borne illnesses (a sickness caused by consuming food or drinks contaminated with harmful substances) in a medically fragile population of 142 residents.Findings:1. During a concurrent observation and record review on 12/8/2025 at 3:12 p.m. in the Main Kitchen, the Hot Food Cooling Log, dated 12/8/2025, was reviewed. There were six portions of corned beef being cooled in the blast chiller (equipment that rapidly cools hot food). The document indicated the Temperature when Cooling Started at 1pm for the six portions of corned beef were #1 - none recorded, #2 - 150 F, #3 - 150 F, #4 - 141 F, #5 - 141 F, #6 - 140 FThe document also indicated, For the cooling process, once the temperature of the food hits 140 F, you have only two hours to get the temperature to 70 Fand an additional four (4) hours for a total of six (6) hours to get the temperature to 41 F. If not, then you must discard the food.During a concurrent observation and interview on 12/8/2025 at 3:13 p.m. with [NAME] Specialist (CS) 1 in the Main Kitchen, the temperatures for six portions of corned beef were checked and recorded as follows: #1 - 109 F, #2 - 99 F, #3 - 98.8 F, #4 - 88.4 F, #5 - 92.5 F, #6 - 96.4 F. CS 1 stated he would keep the corned beef in the blast chiller to continue cooling.During a concurrent observation and interview on 12/8/2025 at 3:15 p.m. with the Food Manager (FM) in the Main Kitchen, CS 1 was observed continuing the cooling process without any corrective actions (interventions such as discarding or reheating to ensure food safety) taken for the six portions of corned beef despite the temperatures not reaching 70 F within two hours. The FM stated the cooling process was okay to be continued without corrective actions taken.During an interview on 12/11/2025 at 8:28 a.m. with CS 2, CS 2 stated if the temperature does not reach 70 F in two hours, but it reaches 40 F in six hours, then the food would still be okay to serve to residents.During an interview on 12/11/2025 at 8:34 a.m. with CS 3, CS 3 stated that after two hours in the cooling process, the temperature may be 120 F to 100 F, but it would be okay to keep cooling. CS 3 further stated that as long as the temperature drops to 41 F after six hours, then the food would still be okay to serve to residents.During an interview on 12/11/2025 at 8:47 a.m. with CS 4, CS 4 stated that because of what happened on 12/8/2025, the FM told staff just this week that after two hours, if the temperature was not 70 F, the food should be discarded.During an interview on 12/11/2025 at 8:51 a.m. with CS 5, CS 5 stated when asked what the interventions were if the temperature did not reach 70 For below in two hours, she did not remember being trained on that by the facility.During a review of the facility document titled, Dietary In-service: Cooling of Potentially Hazardous Foods and Procedures Proper Defrosting of Proteins, undated, the document indicated, Cooling of Meats/Poultry/Gravy/Rice. after you take the food from the oven and start the cooling process and the temp reaches 140*F you have two hours to get the food to 70*F. The document did not include corrective actions to take if the temperature did not reach 70 F within 2 hoursDuring a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Preparation Guidelines, dated 8/9/2025, the P&P indicated, Precooked, extra food, and specified leftovers will be cooled. From greater than 140 F to less than 70 F within two hours, and from 70 F to less than 41 F in an additional four hours. The P&P further indicated, Foods not cooled within the six-hour guideline will either be reheated to 165 F for 15 seconds in two hours and served immediately or discarded, but did not specify which corrective actions to take if the temperature did not reach 70 F within 2 hours.During an interview on 12/11/2025 at 2:36 p.m. with the Director of Dietetics (DD), the DD stated if the temperature does not reach 70 F within two hours of the cooling process, it may be reheated or discarded but not served. The DD further confirmed that the facility's P&P and Dietary In-Service Training did not explicitly include which corrective actions to take if the temperature does not reach 70 F within two hours of the cooling process.During a review of the Food and Drug Administration's Food Code, dated 2022, the Food Code indicated, Safe cooling requires removing heat from food quickly enough to prevent microbial growth. The Food Code indicated, A longer time near ideal bacterial incubation temperatures.70 F - 125 F.is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code also indicated, Cooked hot food may be reheated to 165 F for 15 seconds and the cooling process started again using a different cooling method if the food is above 70 F and two hours or less into the cooling process. The Food Code further indicated, Cooked hot food should be discarded immediately if the food is above 70 F and more than two hours into the cooling process.2. During a concurrent observation and interview on 12/8/2025 at 1:11 p.m. in the Main Kitchen with the Food Manager (FM), the FST was observed operating the dishwasher. The temperature on the dishwasher's display screen remained within the range of 173-177 degrees Fahrenheit ( F, unit of measurement for temperature) during the entire rinse cycle. The FM confirmed the temperature should have reached and been maintained at 180 F but did not.During a concurrent interview and record review on 12/11/2025 at 2:36 p.m. with Food Services Supervisor (FSS) 2, the Sign-In Sheet for In-Service Training, dated January 2025 was reviewed. The document indicated the in-service was for the proper operation of facility dishwashers including appropriate wash/rinse temperature. The document indicated the FST did not receive in-service training. FSS 2 confirmed the FST was on leave when kitchen staff received the in-service and did not receive the training upon returning to work.During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Warewashing Manual & Mechanical, dated 3/17/2025, the P&P indicated, Hot water at a minimum temperature of 180 F will be maintained at the manifold of the final rinse. The P&P further indicated, The Food & Nutrition Services Director or designee is responsible for the training of employees in procedure and documentation of logs.

Based on observation, interview, and record review, the facility failed to ensure food and beverage items for resident consumption were stored in a safe and sanitary manner when: Four boxes of Glucose Control drinks were found stored on the floor.One pound of damaged and unsealed butter was found in the Main Kitchen.Brown sticky residue was found in Unit A3's Common Area Kitchenette's ice machine.These failures had the potential to result in residents being served contaminated or expired foods, which may have led to the spread of food borne illnesses (a sickness caused by consuming spoiled food or drinks contaminated with harmful substances) in a medically fragile population of 142 residents.During a concurrent observation and interview on 12/10/2025 at 11:05 a.m. with Registered Nurse (RN) 1, in the Clean Supply room C231, there were four boxes of Glucose Control drinks found stored on the floor under the handwashing sink. One box was opened and missing several Glucose Control drinks. RN 1 stated the drinks should be placed on the countertop, not on the floor, and began moving the boxes from the floor to the countertop.During an interview on 12/11/2025 at 2:35 p.m. with the Dietetics Director (DD), DD stated food and drinks should never be stored on the floor.During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Storage (All Homes), undated, the P&P indicated, All foods or food items not requiring refrigeration will be stored above the floor, on shelves, racks, dollies, or other surfaces which facilitate thorough cleaning.During a concurrent observation and interview on 12/8/2025 at 2:04 p.m. with the Food Manager (FM) in the Walk-In Refrigerator of the Main Kitchen, a pound of butter was observed with multiple rips in the wrapper. The exposed butter was observed with dented corners. The FM stated the butter looks damaged and should be discarded.During an interview on 12/11/2025 at 2:36 p.m. with the Dietetics Director (DD), the DD stated stored food items in the walk-in refrigerator should not be exposed.During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Services, dated 9/18/2025, the P&P indicated, [facility name] will store food in a safe and sanitary manner.During a review of the Food and Drug Administration's Food Code, dated 2022, Section 3-305.11 indicated, Food shall be protected from contamination by storing the food. where it is not exposed to splash, dust, or other contamination.During a concurrent observation and interview on 12/9/2025 at 3:37 p.m. with Food Services Supervisor (FSS) 1 in Unit A3's Common Area Kitchenette, there was a brown sticky residue wiped with a paper towel from the ice dispenser chute. There was a brown, sticky buildup unevenly distributed along the edges and interior seams of the ice dispenser chute. FSS 1 confirmed the Common Area Kitchenette was accessible and utilized by the unit's residents.During an interview on 12/11/2025 at 9:33 a.m. with the Chief of Plant Operations (CPO), the CPO stated his department was responsible for the maintenance and cleaning of the dispenser chute/spout of the ice machines located in the Unit Common Area Kitchenette. The CPO stated quarterly cleaning and weekly walkthroughs were conducted, but unless someone told their department about the brown sticky substance, they would not know about it. When asked if there should be a brown sticky substance in the ice dispenser chute, the CPO stated he did not know and that such things just happen.During an interview on 12/11/2025 at 2:36 p.m. with the Dietetics Director (DD), the DD stated the brown substance found in the ice dispenser chute should not have been there as it could have been a big source for contamination and bacterial growth.During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation, and Maintenance Policy, dated 5/15/2025, the P&P indicated [facility name] is responsible for cleaning, sanitizing, and maintaining all ice machines in the licensed care area and in the kitchens every three months and as needed.During a review of the facility's P&P titled, Food & Nutrition Services - Sanitation, dated 8/7/2024, the P&P indicated, Ice used in connection with food or drink will be from sanitary source, and will be handled and dispensed in a sanitary manner.During a review of the Food and Drug Administration's Food Code, dated 2022, Section 4-602.11 indicated, .Ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. In addition, If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment.

Based on interview and record review, the facility failed to provide clinical oversight to 142 vulnerable residents in the skilled nursing facility when:1. There was no Medical Director/Chief Medical Officer for the facility.2. Medical Staff credentialing and performance evaluations were not performed according to policy.3. Medical Staff failed to coordinate care between specialties for one of 29 sampled residents (Resident 64).4. The facility failed to adopt any current professional standards of practice for dental services.These failures resulted in a lack of resident care oversight by a Medical Director/Chief Medical Officer, no approval or adoption of current professional standards of practice for dental services and lack of resident care policies and procedures for dental services.Findings:1.During a review of the Facility Assessment, provided by the facility upon entrance, the Facility Assessment indicated, Facility Representatives (names/titles) involved in completing assessment:.Medical Director: (Representative) Physician (MD1) .Date(s) of assessment or update: 11/06/2025. The Facility Assessment further indicated, there was no current Medical Director/Chief Medical Officer and the position was vacant.During a concurrent interview and record review on 12/9/2025 at 12:47 p.m. with the Standards and Compliance Manager (SCM), the Facility Assessment, dated 11/06/2025, was reviewed. The Facility Assessment indicated, the facility did not have a Medical Director/Chief Medical Officer. SCM confirmed the facility did not have Medical Director and MD1 was the Medical Director representative.During an interview on 12/11/2025 at 2:38 p.m. with Administrator (Admin) 1, Admin 1 stated that MD1 was overseeing the clinical medical decisions of the Medical Director/ Chief Medical Officer role. Admin 1 also stated that she was overseeing the administrative portion of the Medical Director/Chief Medical Officer role, which included managing the staff.During an interview on 12/11/2025 at 2:47 p.m. with MD1, MD1 stated that he was not the Medical Director/Chief Medical Officer for the facility and was not in the acting Medical Director/Chief Medical Officer role. MD1 stated in regard to the facility's Medical Director position, I did not accept that role. MD1 confirmed that he did not have any oversight over facility medical staff, and he was in a staff physician role. MD1 stated he reported to Admin 1. MD1 confirmed that the facility currently did not have Medical Director/Chief Medical Officer.During an interview on 12/11/2025 at 5:00 p.m. with Admin 1, Admin 1 confirmed Medical Director/Chief Medical Officer position had been vacant since April 2025. Admin 1 stated that the facility did not notify California Department of Public Health of change in Medical Director/Chief Medical Officer position.During a review of MD1's Job Duty Statement, dated 9/4/2025, the Job Duty Statement indicated, Class Physician and Surgeon.Under the general supervision of the Chief Medical Officer for [the facility], is responsible for the medical care of an assigned group of residents and supervision of nurses, attendants, and others engaged in the care of residents. There was no documentation in MD1's Job Duty Statement which indicated MD1 had supervision of facility medical staff duties.During a review of the Job Duty Statement for the Medical Director position dated 6/4/2018, the Job Duty Statement indicated essential functions included: providing administrative oversight of primary medical, dental, and onsite specialty care services to effectively attain the medical care standards providing for the overall care for the resident population.During a review of the facility's Organizational Chart: Medical Staff Admin/Dental/Medical/Mental Health/Pharmacy, dated January 2026, the Organizational Chart indicated, the Medical Director/Chief Medical Officer role was vacant.2. During a concurrent interview and record review with the credentialing (the process of verifying a healthcare provider's qualifications, education, licenses, training, experience and competency to ensure they meet professional standards for safe and effective resident care, allowing them to practice at the facility) Staff Service Analyst (SSA), SSA stated when members of the medical staff applied for initial credentialing or re-credentialing, he coordinated the necessary documents for the credentialing packet and provided it to the Credentialing Committee for review. SSA stated the committee consisted of the Medical Director/Chief Medical Officer and a credentialing specialist. SSA stated the facility was currently without a Medical Director and the Administrator (Admin 1) was filling in that role.The facility's policy titled, Practitioner Credentialing dated 7/8/2025 was reviewed with SSA. According to the policy, Re-credentialling is required one year after the initial credentialing and then every two years thereafter. The policy also indicated the practitioner's performance should be reviewed and assessed annually by the Medical Director/Chief Medical Officer. The policy indicated, The individual record of experience will be reviewed annually for each applicant based on peer review and or performance improvement data. According to the policy, the Medical Director/Chief Medical Officer was responsible for the implementation and enforcement of the credentialing process.During an interview with Admin 1 on 12/11/2025 at 5 p.m., Admin 1 stated the facility has been without a Medical Director since April 2025.During a concurrent interview and record review on 12/12/2025 at 12:52 p.m. with Admin 1, Dentist 1's initial credential file was reviewed. Dentist 1 was initially credentialed on 6/23/2024. There was no documentation of an annual performance evaluation from June 2025 to present, and Dentist 1 did not go through the annual re-credentialling process in June 2025 per policy. Admin 1 confirmed Dentist 1's re-credentialing and performance evaluation was not conducted per policy. In addition, Admin 1 confirmed Medical Staff performance evaluations were not being conducted while the Medical Director/Chief Medical Officer position was vacant.During a review of the Job Duty Statement for the Chief Medical Officer dated 6/4/2018, the Job Duty Statement indicated, The Chief Medical Officer's Essential Functions included, Oversee the credentialling process for health practitioners to resident veterans. 3. During the survey, deficient practice was identified related to the coordination of care between the physician and the dentist which resulted in a 41-day delay of care for Resident 64 when he was unable to attend his dental procedure because pre- procedure orders were not documented and implemented. (Refer to F790).During a review of Resident 64's Physician Progress Notes dated 9/8/2025, the physician (MD 2) documented, The primary indication for teeth extractions is to prevent lower gum pain/irritation/lesions. MD 2 further documented, Recommendations: ASA (aspirin) to be discontinued 7 days prior to procedure, 1 mg (milligram- unit of measure) Lorazepam (mediation used to help people relax before surgery) 1 hour prior to the procedure, 2 gm Amoxicillin (antibiotic given prior to surgery to prevent infections) 1 hour prior to procedure at time of departure. [Dentist 1] will coordinate and order.During a review of the Dentist Pre-Op Surgery Consult dated 10/27/2025, Dentist 1 documented, [Resident] is scheduled for oral surgery on 11/5/2025 and in consultation with MD 2. we could do a pre-med with standard 2 grams of amoxicillin. to be given at 12:00 before his appointment at 1:00 pm.During an interview on 12/11/2025 at 1:27 p.m. with Dentist 1, Dentist 1 stated Resident 64 needed oral surgery to remove multiple broken and decayed teeth and eventually be fitted with dentures. Dentist 1 further stated Resident 64's did not attend his appointment for his procedure on 11/5/2025 because he was supposed to receive pre-procedure medications and the orders were not documented and implemented. Dentist 1 stated it was not her responsibility to document orders in the record. Dentist 1 stated she was not responsible for writing orders to hold medications or give pre-medications. Dentist 1 stated this was the primary physician's responsibility and had been since she started working at the facility.During an interview on 12/11/2025 at 2:38 p.m. with Admin 1, Admin 1 stated she was unaware who was responsible for documenting the pre-procedure orders in Resident 64's record. Admin 1 stated MD 1 was available as a Medical Director/Chief Medical Officer designee for Medical Staff issues and was overseeing the clinical medical decisions of the Medical Director/Chief Medical Officer role.During an interview with MD 1, MD 1 stated he was not the Medical Director/Chief Medical Officer or designated Medical Director/Chief Medical Officer and had no supervisory responsibilities. MD 1 stated, I did not accept that role; I am a staff physician. MD 1 stated he was unaware who was responsible for documenting pre-procedure orders for Resident 64 and stated the providers should have coordinated. MD 1 was also unaware if the facility had policies related to who was responsible for documenting orders for pre dental procedures.During a joint interview with Admin 1 and the Standards and Compliance Manager (SCM) on 12/11/25 at 5 p.m., SCM stated Dentists are members of the Medical Staff but had different documentation requirements than the physicians; however, SCM was unable to state what the documentation requirements were. SCM confirmed the facility did not have policies related to Dentist documentation expectations.During a review of the facility's Job Duty Statement for the Chief Medical Officer dated 6/4/2018, the Job Duty Statement indicated Essential Functions of the role included, Provide administrative oversite of primary medical, dental and onsite specialty care services to effectively attain the medical care standards providing for the overall care for the resident veteran population.During a review of Dentist 1's Job Duty Statement, dated 8/05/2024, the Job Duty Statement indicated, Class: Dentist. Under the supervision of the Administrator and general direction of the Chief Medical Officer.Establish policies and procedures regarding dental care at the facility.During the survey, the facility was unable to identify who was responsible for documenting Resident 64's pre- procedure dental orders. In addition, the facility was unable to produce, upon request, any written and approved resident care policies indicating the facility's goals, directives, and governing statements that direct expectations for coordination of care between the physicians and dentists and documentation responsibilities.4. During an interview on 12/11/2025 at 2:45 p.m. with the Administrator (Admin) 1, Admin 1 stated she is currently filling the Medical Director/Chief Medical Officer position for administrative issues. Admin 1 stated, Dentist 1 follows dental industry standards of practice but could not confirm which professional dental standards the dentist follows. During an interview on 12/12/2025 at 11:47 a.m. with Director of Nursing (DON), Standards and Compliance Manager (SCM), Administrator (Admin) 2. DON, SCM and Admin 2 were asked, who had been providing clinical oversite for the skilled nursing facility medical services including dental. None of the Administrative staff provided an answer to the question indicating who was responsible for clinical oversight. DON, SCM and Admin 2 were asked, who writes resident care policies for dental services. None of the Administrative staff provided an answer to the question indicating who was responsible. DON, SCM and Admin 2 were asked, what dental industry standards had the facility adopted and or approved. None of the Administrative staff provided an answer to the question indicating what dental industry standards had been adopted and or approved. During an interview on 12/11/2025 at 1:27 p.m. with Dentist 1, Dentist 1 was asked who her supervisor was, Dentist 1 stated, I currently report to the Home Administrator (Admin 1)as my supervisor, we do not have a Chief Medical Officer.During an interview, on 12/11/2025 at 5:00 p.m., with the Admin 1 and SCM, Admin 1 and SCM were asked if there were written approved and implemented medical staff rules, regulations or bylaws related to dental care. Admin 1 stated, there are no bylaws but there are policies for the medical staff related to certain dental procedures. SCM and Admin 1 were asked, what were the requirements for documentation for dentists in the facility, SCM stated she had been researching dental documentation requirements and had not found anything by statute just industry standard of practice. SCM confirmed the facility dentist is a member of the medical staff but has different documentation requirements from the medical doctors, which are industry standards of practice. SCM and Admin 1 were unable to say which industry standards of practice the facility used for dental care. During a review of Dentist 1's Job Duty Statement, dated 8/05/2024, the Job Duty Statement indicated, Class: Dentist. Under the supervision of the Administrator and general direction of the Chief Medical Officer.Establish policies and procedures regarding dental care at the facility.

Based on interview and record review, the facility failed to notify the California Department of Public Health (CDPH) in any capacity when the Medical Director/Chief Medical Officer position was vacated on 5/3/2025 with no replacement or interim physician in place. This failure resulted in the state agency being unable to provide timely oversight or intervention and resulted in allowing residents to remain for an extended period without required medical leadership and safeguards, thereby increasing the risk of delayed medical care, inadequate supervision over medical services, and potential harm to a medically compromised population of 142 residents. Refer to related deficiency F0841.During an interview on 12/12/2025 at 11:20 a.m. with the Standards and Compliance Manager (SCM), the SCM stated MD 3 was the interim Medical Director/Chief Medical Officer from January to May 2025. The SCM further stated when MD 3 left in May 2025 with no interim physician in place, the facility did not notify CDPH in any capacity of the lack of a Medical Director/Chief Medical Officer. The SCM stated the facility thought they had it under control.During an interview on 12/12/2025 at 12:44 p.m. with Nurse Practitioner (NP) 1, NP 1 stated there was no Medical Director/Chief Medical Officer currently in place. NP 1 stated she discussed her cases with a physician but did not have a designated physician supervisor to whom she reported.During a review of the facility's organizational chart titled, Medical Staff Admit/Dental/Mental Health/Pharmacy, dated January 2026, the chart indicated the Chief Medical Officer position was vacant.During a review of the facility's Medical Director/Chief Medical Officer's Duty Statement, undated, the document indicated the Medical Director/Chief Medical Officer was responsible to plan, organize, and direct the medical program of the facility.

Based on observation, interviews, and record review, the facility failed to ensure a controlled access medication storage room was secured when three contracted surveillance camera technicians were allowed access to the medication room containing dangerous medications, with no supervision or monitoring by licensed clinical staff.This failure had the potential for dangerous medication diversion (illegally taking prescription drugs from their intended path for unauthorized use, to use themselves, give to others, or sell, by unlicensed personnel) which could have led to medication related illness, injury and or death.During an observation on 12/08/25 1:50 p.m., a controlled badge-access medication storage room (E-342) door was propped open, with three contracted surveillance camera technicians in the medication room with no supervising or monitoring licensed clinical personnel.During an Interview on 12/08/25 at 1:53 p.m. with Supervising Registered Nurse (SRN2), SRN2 stated, I let them in there this morning and should not have. I should have had a licensed staff member monitoring the technicians.During an interview on 12/10/25 at 3:59 p.m. with the Director of Nursing (DON), DON stated, Although the cabinets and drawers were locked, there should have been a licensed staff member supervising or monitoring the medication room while it was unsecured.Review of facility policy and procedure titled, Storage of Medications, dated 9/26/25 indicated, Purpose: To establish criteria whereby medications are stored securely while maintaining necessary accessibility and viability as required by legal and regulatory agencies. Policy: Drugs shall be stored in a manner that will keep them safe, effective and secure.Security and Handling of Medications: All medications in the facility are locked, contained in a room, in a locked controlled access, or under constant surveillance. In addition, controlled substances are kept in locked cabinets in locked, controlled access rooms (pharmacy and nursing medication rooms or medication carts) .

Based on observation, record review, and interview, the facility did not ensure that Resident 12, one of the 29 sampled residents, was afforded the right to a dignified existence and the right to make decisions regarding his care and services. Resident 12 expressed concerns to the facility staff about feeling unsafe with the facility's bus drivers' use of the mechanical lift for boarding the bus.This oversight led to Resident 12 missing medical appointments due to emotional distress related to safety concerns, thereby violating his rights.Findings: During a review of Resident 12's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (loss of movement and sensation in arms, legs, and torso), spinal stenosis (narrowing of the spaces within the spine), and anxiety disorder (mental health condition that causes excessive and uncontrollable worry and fear that goes beyond normal stress.) During a review of Resident 12's Minimum Data Set (MDS- An assessment care-planning tool), dated 6/26/2025, the MDS indicated, Resident 12 had the ability to understand others and make himself understood by others. During a concurrent observation and interview on 12/8/2025 at 1:53 p.m. with Resident 12, Resident 12 was observed seated in his electric wheelchair. Resident 12 stated that transportation to his physical therapy appointments had been an issue. Resident 12 stated the facility's bus ramps had a difficult time lifting him onto the bus and there was only one facility bus driver (Bus Driver 1) that knew how to use the bus ramp to get him onto the bus. Resident 12 also stated he only felt safe with Bus Driver 1, who knew how to safely get him onto the bus and did not feel safe with the other two bus drivers at the facility because he had gotten stuck on the bus ramp with one of the two bus drivers. During an observation on 12/9/2025 at 9:40 a.m., Resident 12 was observed seated in his electric wheelchair in the facility's courtyard with the facility's bus parked in front of the courtyard. At 9:41 a.m., Resident 12 drove his electric wheelchair onto the bus ramp, with Administrator (Admin) 1 and two transportation staff members next to the bus ramp. Resident 12 was seated in his electric wheelchair parked on the bus ramp for approximately 6 minutes with transportation staff at the bus ramp. At 9:47 a.m., Resident 12 was observed driving his electric wheelchair off of the bus ramp. At 9:56 a.m., a second facility bus arrived and parked in front of the facility courtyard. The second bus driver (Bus Driver 1) lifted Resident 12 safely onto the facility bus with the bus ramp. During an interview on 12/10/2025 at 8:29 a.m. with Resident 12, Resident 12 stated he experienced some trouble getting onto the bus on 12/9/2025. Resident 12 stated he was able to attend his appointment yesterday because Bus Driver 1 who he felt safe with was able to get him safely onto the bus. Resident 12 stated that he had communicated with staff about his transportation concerns for approximately 4-5 months. Resident 12 also stated that he informed the Interdisciplinary Team (IDT-group of health care professionals from different fields who work together toward the goals of their patients) in an IDT meeting of his concerns regarding transportation safety, and his concerns were dismissed. Resident 12 stated that the transportation issues and concerns has caused him to become distressed and stated, The whole thing has cause me to lose sleep. During an interview on 12/10/2025 at 1:35 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 has been having transportation issues because he only felt safe with one facility bus driver and does not feel safe with the other 2 bus drivers. CNA 1 stated that Resident 12 has experienced agitation and anxiety because of transportation concerns. CNA 1 also stated that Resident 12 has missed medical appointments because of safety issues with transportation. During an interview on 12/10/2025 at 1:47 p.m. with Social Worker (SW) 1, SW1 stated that Resident 12 is very cognitive (mental processes involved in gaining knowledge and comprehension) aware. SW1 stated that Resident 12 has gotten stuck on the facility's bus ramp when a bus driver was getting Resident 12 onto the bus, which has caused Resident 12 to feel unsafe with two of the facility's bus drivers. SW1 stated that Resident 12 has experienced increased distress and anxiety related to his transportation concerns and issues. During an interview on 12/10/2025 at 2:41 p.m. with Supervisor Registered Nurse (SRN) 1, SRN1 stated that Resident 12 has missed appointments recently due to transportation safety concerns. SRN1 stated that Resident 12 does not feel safe with two of the facility's bus drivers. SRN1 stated that she sent email communication on 12/2/2025 to the facility's administration about Resident 12's safety concerns with the two bus drivers. SRN1 stated that Resident 12 has been having trouble sleeping because he has been experiencing anxiety related to his concerns regarding transportation to his medical appointments. During an interview on 12/11/2025 at 11:50 a.m. with Standard and Compliance Manager (SCM), SCM stated that Resident 12's transportation to appointments were cancelled on the following dates: 12/8/2025, cancelled because Resident 12 refused assigned bus driver because the bus driver was one he did not feel safe with; 12/1/2025, cancelled due to driver availability; 11/26/2025, cancelled because of bus driver incapability. During an interview on 12/11/2025 at 11:32 a.m. with Supervisor Social Worker (SSW) 1, SSW1 stated that Resident 12 is very honest and has been very accurate with describing past events. During a review of Resident 12's Interdisciplinary Team (IDT) Meeting Report, dated 11/14/2025, the IDT Meeting Report indicated, Resident brought up a different concern regarding the ramp for the bus. He said that the ramp is too short making it hard for him to maneuver to get into the bus. He points out that [Nurse Practitioner] who happened to be present tried to help him get on the bus. He was redirected to focus on the topic at hand.but resident stated that he is voicing out his concerns and part of this meeting is to listen to what his concerns are. There was no documentation in Resident 12's record which indicated the IDT met with the resident to discuss his transportation concerns after the 11/14/2025 meeting. During a review of Resident 12's Nursing Notes, dated 11/26/2025, the Nursing Notes indicated, Resident had urology (medical specialty focusing on the urinary tract), lab and x-ray appointment today. However, he refused to go to the appointment. Spoke with resident and he stated that he would go to his appointments only with one of drivers [Bus Driver 1]. He stated that he spoke with drivers' supervisor and he mentioned the safety concerns that he has. During a review of Resident 12's Nursing Notes, dated 12/2/2025, the Nursing Notes indicated, [Resident 12] wants to cancel appointments today. He said that he feels not safe with [bus driver]. He only trusts [Bus Driver 1]. He said that last time he got stuck mid air and was afraid of falling off. He added that he was not buckled in properly. During a review of Resident 12's Nursing Notes, dated 12/8/2025, the Nursing Notes indicated, Received report regarding resident missing his appointments this morning as he did not feel safe with the driver that was going to take him to his appointment. He said that the driver that he feels safe with was available but he was told that another driver was going to take him instead. Sent email to administration: '[Resident 12] came back to the unit because he was assigned to [bus driver] today.He missed his appointment this morning.Please advise.' Sent another email message to administration: 'To give more insight:.[Resident 12] said that it is not a preference for [Bus Driver 1] but a need to feel safe.During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team Conference, dated 5/27/2025, the P&P indicated, The purpose of the Interdisciplinary Team is to develop and maintain an interdisciplinary plan of care that meets the individual and changing needs of the Resident in the Skilled Nursing Facility.

Based on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 12) maintained the highest mental and psychosocial well-being when Resident 12 communicated to the facility staff that he did not feel safe with the facility's bus drivers using the mechanical lift to assist him onto the bus.This failure resulted in Resident 12 missing his medical appointments due to emotional distress and safety issues.Findings:During a review of Resident 12's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (loss of movement and sensation in arms, legs, and torso), spinal stenosis (narrowing of the spaces within the spine), and anxiety disorder (mental health condition that causes excessive and uncontrollable worry and fear that goes beyond normal stress.)During a review of Resident 12's Minimum Data Set (MDS- An assessment care-planning tool), dated 6/26/2025, the MDS indicated, Resident 12 had the ability to understand others and make himself understood by others.During a concurrent observation and interview on 12/8/2025 at 1:53 p.m. with Resident 12, Resident 12 was observed seated in his electric wheelchair. Resident 12 stated that transportation to his physical therapy appointments had been an issue. Resident 12 stated the facility's bus ramps had a difficult time lifting him onto the bus and there was only one facility bus driver (Bus Driver 1) that knew how to use the bus ramp to get him onto the bus. Resident 12 also stated he only felt safe with Bus Driver 1, who knew how to safely get him onto the bus and did not feel safe with the other two bus drivers at the facility because he had gotten stuck on the bus ramp with one of the two bus drivers.During an observation on 12/9/2025 at 9:40 a.m., Resident 12 was observed seated in his electric wheelchair in the facility's courtyard with the facility's bus parked in front of the courtyard. At 9:41 a.m., Resident 12 drove his electric wheelchair onto the bus ramp, with Administrator (Admin) 1 and two transportation staff members next to the bus ramp. Resident 12 was seated in his electric wheelchair parked on the bus ramp for approximately 6 minutes with transportation staff at the bus ramp. At 9:47 a.m., Resident 12 was observed driving his electric wheelchair off of the bus ramp. At 9:56 a.m., a second facility bus arrived and parked in front of the facility courtyard. The second bus driver (Bus Driver 1) lifted Resident 12 safely onto the facility bus with the bus ramp.During an interview on 12/10/2025 at 8:29 a.m. with Resident 12, Resident 12 stated he experienced some trouble getting onto the bus on 12/9/2025. Resident 12 stated he was able to attend his appointment yesterday because Bus Driver 1 who he felt safe with was able to get him safely onto the bus. Resident 12 stated that he had communicated with staff about his transportation concerns for approximately 4-5 months. Resident 12 also stated that he informed the Interdisciplinary Team (IDT-group of health care professionals from different fields who work together toward the goals of their patients) in an IDT meeting of his concerns regarding transportation safety, and his concerns were dismissed. Resident 12 stated that the transportation issues and concerns has caused him to become distressed and stated, The whole thing has cause me to lose sleep.During an interview on 12/10/2025 at 1:35 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 12 has been having transportation issues because he only felt safe with one facility bus driver and does not feel safe with the other 2 bus drivers. CNA 1 stated that Resident 12 has experienced agitation and anxiety because of transportation concerns. CNA 1 also stated that Resident 12 has missed medical appointments because of safety issues with transportation.During an interview on 12/10/2025 at 1:47 p.m. with Social Worker (SW) 1, SW1 stated that Resident 12 is very cognitive (mental processes involved in gaining knowledge and comprehension) aware. SW1 stated that Resident 12 has gotten stuck on the facility's bus ramp when a bus driver was getting Resident 12 onto the bus, which has caused Resident 12 to feel unsafe with two of the facility's bus drivers. SW1 stated that Resident 12 has experienced increased distress and anxiety related to his transportation concerns and issues.Durning an interview on 12/10/2025 at 2:41 p.m. with Supervisor Registered Nurse (SRN) 1, SRN1 stated that Resident 12 has missed appointments recently due to transportation safety concerns. SRN1 stated that Resident 12 does not feel safe with two of the facility's bus drivers. SRN1 stated that she sent email communication on 12/2/2025 to the facility's administration about Resident 12's safety concerns with the two bus drivers. SRN1 stated that Resident 12 has been having trouble sleeping because he has been experiencing anxiety related to his concerns regarding transportation to his medical appointments.Durning an interview on 12/11/2025 at 11:50 a.m. with Standard and Compliance Manager (SCM), SCM stated that Resident 12's transportation to appointments were cancelled on the following dates: 12/8/2025, cancelled because Resident 12 refused assigned bus driver because the bus driver was one he did not feel safe with; 12/1/2025, cancelled due to driver availability; 11/26/2025, cancelled because of bus driver incapability.During an interview on 12/11/2025 at 11:32 a.m. with Supervisor Social Worker (SSW) 1, SSW1 stated that Resident 12 is very honest and has been very accurate with describing past events.During a review of Resident 12's Interdisciplinary Team (IDT) Meeting Report, dated 11/14/2025, the IDT Meeting Report indicated, Resident brought up a different concern regarding the ramp for the bus. He said that the ramp is too short making it hard for him to maneuver to get into the bus. He points out that [Nurse Practitioner] who happened to be present tried to help him get on the bus. He was redirected to focus on the topic at hand.but resident stated that he is voicing out his concerns and part of this meeting is to listen to what his concerns are. There was no documentation in Resident 12's record which indicated the IDT met with the resident to discuss his transportation concerns after the 11/14/2025 meeting.During a review of Resident 12's Nursing Notes, dated 11/26/2025, the Nursing Notes indicated, Resident had urology (medical specialty focusing on the urinary tract), lab and x-ray appointment today. However, he refused to go to the appointment. Spoke with resident and he stated that he would go to his appointments only with one of drivers [Bus Driver 1]. He stated that he spoke with drivers' supervisor and he mentioned the safety concerns that he has.During a review of Resident 12's Nursing Notes, dated 12/2/2025, the Nursing Notes indicated, [Resident 12] wants to cancel appointments today. He said that he feels not safe with [bus driver]. He only trusts [Bus Driver 1]. He said that last time he got stuck mid air and was afraid of falling off. He added that he was not buckled in properly.During a review of Resident 12's Nursing Notes, dated 12/8/2025, the Nursing Notes indicated, Received report regarding resident missing his appointments this morning as he did not feel safe with the driver that was going to take him to his appointment. He said that the driver that he feels safe with was available but he was told that another driver was going to take him instead. Sent email to administration: '[Resident 12] came back to the unit because he was assigned to [bus driver] today.He missed his appointment this morning.Please advise.' Sent another email message to administration: 'To give more insight:.[Resident 12] said that it is not a preference for [Bus Driver 1] but a need to feel safe.'During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team Conference, dated 5/27/2025, the P&P indicated, The purpose of the Interdisciplinary Team is to develop and maintain an interdisciplinary plan of care that meets the individual and changing needs of the Resident in the Skilled Nursing Facility.

Based on interviews and record review, the facility failed to provide routine dental care services to meet the needs of two of 29 sampled residents (Resident 26 and Resident 64).These failures resulted in a delay in care when:1.Resident 26 experiencing an 89-day delay in receiving further treatment for lingering unaddressed dental issues as Resident 26 waited for referral to an outpatient specialty dental provider.2. Resident 64's dental procedure was cancelled and could not be rescheduled for 41 days. 1.During a review of Resident 26's medical record, the record indicated, Resident 26 was a [AGE] year-old resident of the locked memory care unity with a history of dementia (progressive or persistent loss of intellectual functioning and memory), hypertension (high blood pressure) and stroke (when blood flow to part of the brain is cut off, either by a blockage or bleeding, depriving brain cells of oxygen and nutrients, causing them to die within minutes and leading to potential lasting damage, disability). During an observation on 12/9/25 at 9:35 a.m., Resident 26 was observed in the activity room, unable to interview and unable to answer any questioning due to being primarily non-verbal. Resident 26 was able to open his mouth slightly and no dentures were visible. During an interview on 12/10/25 at 8:37 a.m. Supervising Registered Nurse (SRN2), SRN2 stated, No I cannot find any other note by the dentist on the date of service and examination for 9/10/25. SRN2 stated, Usually the dentist would write a note the day of the resident exam. During an interview on 12/11/25 at 1:27 p.m. with Dentist 1, Dentist 1 stated, she examined Resident 26 on 9/10/2025 and wrote a clarification note on 12/8/2025. During a review of Resident 26's Dental Hygienist Note dated, 9/10/25 indicated, Patient mouth debridement, exam. Reviewed medical history, CNA stayed with the resident at chairside.Resident was not very cooperative.slides down in the chair, closes his lips when anything is placed in his mouth. Resident is too uncooperative for dental x-rays and will need several cleanings. Refer to the outpatient specialty dental clinic for treatment with sedation including evaluation for extraction of number 6 tooth.refer to outpatient specialty dental clinic. During a review of Resident 26's medical record, there was no documentation of referral made to the outpatient specialty clinic. During a review of Resident 26's Dentist Note dated, 12/8/25 indicated, date of examination 9/10/25 3:51 p.m. dentist exam refused by patient. Due to mental status changes patient is not a candidate for referrals and due to the aggressive personality and mental state patient may not be accepted for treatment at the outpatient specialty dental clinic. The facility was unable to provide a dental policy applicable to the identified issue. 2. Review of the Face Sheet (Resident Demographics) indicated Resident 64 was admitted to the facility on [DATE] with diagnoses which included dysphasia (difficulty swallowing). During an interview on 12/8/2025 at 4:53 p.m. with Resident 64 and his family member (FM 1), Resident 64 stated he had difficulty chewing regular food due to his teeth. FM 1 reported Resident 64 was scheduled for a dental procedure at a local hospital on [DATE] to have extractions (teeth removed) to eventually be fitted with dentures. FM1 reported the resident's procedure was canceled because, They forgot to hold his aspirin (blood thinning medication). Resident 64 stated he was growing tired of eating mashed potatoes and was looking forward to getting closer to being fitted with dentures so that he could eat more varieties of foods. During a review of the Physician Progress Notes dated 9/8/2025, the physician (MD 2) documented, The primary indication for teeth extractions is to prevent lower gum pain/irritation/lesions. MD 2 further documented, Recommendations: ASA (aspirin) to be discontinued 7 days prior to procedure, 1 mg (milligram- unit of measure) Lorazepam (mediation used to help people relax before surgery) 1 hour prior to the procedure, 2 gm Amoxicillin (antibiotic given prior to surgery to prevent infections) 1 hour prior to procedure at time of departure. [Dentist 1] will coordinate and order. During a review of the Dentist Pre-Op Surgery Consult dated 10/27/2025, Dentist 1 documented, [Resident] is scheduled for oral surgery on 11/5/2025 and in consultation with MD 2. we could do a pre-med with standard 2 grams of amoxicillin. to be given at 12:00 before his appointment at 1:00 pm. During a concurrent interview and review of Resident 64's orders, dated 9/8/2025-12/8/2025, with Registered Nurse (RN) 1, the physician's order dated 8/25/2025 indicated Resident 64 received 81 mg of aspirin every day. This order was discontinued on 11/16/2025 (11 days after Resident 64's scheduled dental procedure. RN 1 confirmed there were no orders in Resident 64's record instructing staff to hold aspirin, give Lorazepam, or give Amoxicillin prior to his dental procedure on 11/5/2025. RN 1 stated Resident 64's dental procedure was cancelled because the medication changes were not implemented. RN1 stated, the nursing staff needed orders to hold or administer medications. During an interview on 12/11/2025 at 1:27 p.m. with Dentist 1, Dentist 1 stated Resident 64 needed oral surgery to remove multiple broken and decayed teeth and eventually be fitted with dentures. Dentist 1 stated she made recommendations, arranged the procedure, and Resident 64's transportation to the procedure, but it was not her responsibility to document orders in the record. Dentist 1 stated she was not responsible for writing orders to hold medications or give pre-medications. Dentist 1 stated this was the primary physician's responsibility and had been since she started working at the facility. During an interview on 12/11/2025 at 2:38 p.m. with the Administrator (Admin) 1, Admin 1 stated she was unaware who was responsible for documenting Resident 64's pre-procedure orders in the record (Dentist 1 or MD 2). During a concurrent interview on 12/12/2025 at 12:52 p.m., Dentist 1's Credential File dated 7/23/2024 was reviewed with Admin 1. According to the Credential File, Dentist 1 was granted privileges including Prescription of medication pertinent to treatment or intra-oral conditions and in consultation with ward physician where desired. During the survey, the facility was unable to produce, upon request, any written and approved resident care policies indicating the facility's goals, directives, and governing statements that direct expectations for coordination of care between the physicians and dentists and documentation responsibilities.

Based on observation, interview, and record review, the facility failed to implement a physician's order for a fall mat for one of 29 sampled residents, Resident 49.This failure resulted in the potential for Resident 49 sustaining an injury in the event of a fall.Findings:During a review of the Face Sheet (Resident Demographics) the Face Sheet indicated, Resident 49 was admitted to the facility on [DATE] with diagnosis including Right side weakness and history of Cerebro Vascular Accident (CVA - a medical condition when there is a loss of blood flow to part of the brain).During a concurrent observation and interview on 12-8-2025 at 3:58p.m. with Resident 49, Resident 49 was observed with bandages on left arm and right hand while sitting up in his wheelchair. Resident 49 stated that he fell a couple of days ago from his bed onto the floor. Resident 49 stated that he was on the floor for 5 minutes before help arrived. No safety fall mat is observed in the room.During an observation on 12-9-2025 at 3:26p.m., Resident 49 was observed lying in his bed. There was a safety fall mat observed rolled up and leaning against Resident 49's bed.During a concurrent observation and interview on 12-9-2025 at 3:28p.m. with Certified Nursing Assistant (CNA) 2 in Resident 49's room, Resident 49 was observed lying in bed. The safety fall mat was observed rolled up and leaning against Resident 49's bed. CNA 2 stated that Resident 49 should have the safety fall mat unrolled and placed on the floor next to his bed. CNA 2 unrolled the safety fall mat and placed it on the floor.During an interview with Registered Nurse (RN) 1 on 12-11-2025 at 9:24a.m., RN 1 stated that fall mats were used to prevent injury for residents identified as high risk for falls. Per RN 1, the fall mat is expected to be unrolled on the floor next to the bed at all times when Resident 49 was in bed.During a review of Resident 49 's Fall Risk Assessment, dated 9-5-2025, the Fall Risk Assessment identified Resident 49 as high risk for falls.During a review of Resident 49's physician's order dated 6-19-2025, the physician's order indicated, Floor mat next to bed for fall precaution.A review of Resident 49's Care Plan Report dated 12-10-2025 indicated, Resident 49 is at risk for falls/ fall related injury: history of fall, history of CVA. Floor mat next to bed as ordered.During a record review of the facility's Policy and Procedure (P &P) titled Accident / Fall Prevention, last reviewed 5-29-2025, facility's P &P indicated, the facility will routinely assess each Skilled Nursing Facility (SNF) resident for risk of accidents and implement preventive measures to decrease modifiable risks, as able.

Based on observation, interviews, and record reviews, the facility failed to timely follow up on the dental treatment recommended for one of two residents (Resident 1). On 9/17/2024, the dentist had recommended oral surgery for Resident 1. This failure had resulted in fluctuates of Resident 1's mood and potentially affecting his overall quality of life. The referral for the oral surgery was only sent again by the facility on 6/25/2025, which was a delay of 281 days, equivalent to 9 months and 8 days. During an observation and concurrent interview on 8/19/25 at 12:30 p.m. with Resident 1, a [AGE] year-old male with a history of dementia (progressive or persistent loss of intellectual functioning and memory), atrial fibrillation (abnormal heart rhythm), and poor dentition, was observed with upper front teeth (numbers 7-10) visibly missing or decayed, eating mashed potatoes. Resident 1 stated, he lost his front teeth years ago and stopped using his partial lower dentures due to pain. Resident 1 stated, the dentist had told him he needed oral surgery, but no follow-up occurred.During an interview on 8/19/25 at 12:45 p.m. with the Registered Dietitian (RD), RD stated, the facility had placed Resident 1 on a long-term soft diet due to dental issues. The RD stated, Resident 1 had requested dentures multiple times.During an interview on 8/19/25 at 2:55 p.m. with the Director of Nursing (DON), DON explained, Resident 1 experienced delays in care coordination because Resident 1 needed to have medical clearance before oral surgery, due to multiple comorbidities.During a telephone interview on 8/20/25 at 11:30 a.m. with Resident 1's Durable Power of Attorney (DPOA), DPOA stated, Resident 1 had been waiting nearly a year for extractions and dentures since the dentist referred Resident 1 for oral surgery in September 2024. Despite multiple follow-ups with the dentist and social worker, the DPOA observed Resident 1 had little to no progress with dental care.During a telephone interview on 8/20/25 at 3:42 p.m. with the dentist (DDS), DDS stated, Resident 1 had been evaluated emergently in September 2024, and referred Resident 1 for oral surgery and created a denture plan. DDS stated, a misunderstanding with the DPOA caused the delays in dental care and required the DDS to reinitiate the referral in June 2025.During an interview on 8/21/25 at 9:30 a.m. with a social worker (SW), SW stated, Resident 1's DPOA had been coordinating Resident 1's dental care and there was confusion regarding where Resident 1 was supposed to go for oral surgery. SW stated, Resident 1 had expressed he was feeling situational depression due to lack of dentures and the inability to eat solid food.Review of emergency dental note dated 9/17/2024 at 4:48 p.m. indicated, Resident 1 was evaluated as an emergency and was complaining of pain in the upper jaw with increasing severity over the previous few days and weeks. Grossly decayed anterior (front) teeth numbers 7,8,9,10. Dietary staff are informed of change in diet will be needed until lower appliance is made. Referral made to specialty clinic for multiple extractions. Treatment plan for full upper dentures (FUD) and partial lower dentures (PLD).Review of dental note dated 9/25/2024 3:41 p.m. indicated, Intra oral (in the mouth) and extra oral (outside the mouth) exams performed. Treatment plan was completed and presented to Resident 1 and DPOA. Prescription given: Resident 1 referred to outside oral surgeon for extraction of teeth, 2,3,6,7,8,9,10,11,14,15. Diet texture modifications needed: Dietary staff is aware of his dental condition and will be informed when change in diet will be needed when extractions are done and new appliance (dentures) are made.Review of social service note dated, 11/12/24 at 10:03 a.m. indicated, Social Work Quarterly Assessment: Resident 1's DPOA reported that Resident 1 had ongoing situational depression, and it primarily surrounded the difficulty and struggles of being wheelchair bound and being on a modified diet. Resident 1 stated, Yeah, if I could eat anything I want and walk my life would be a lot better. DPOA stated, We are currently working with the facility to get Resident 1 assigned to a dentist that has special equipment to care for him.There was no documentation Resident 1 received any further evaluation or follow-up regarding dental care between 11/12/24 and 5/12/25.Review of social service note dated 5/12/25 at 1:21 p.m. indicated, Resident 1's DPOA reported Resident 1's mood varied from day to day. DPOA stated, most of it had to do with Resident 1's situation with the dentist and needing teeth removed. The plan was to have Resident 1 go to an outside oral surgeon to get them removed and nothing had been done. Resident 1 stated to SW, Yes, If I can get my new dentures, my quality of life would be better, eating mushed up food is not as filling or satisfying.Review of Dental Note dated, 6/25/25 09:57 p.m. indicated, Prescription (for oral surgery) given referral to be sent again with diet texture modifications needed: Dietary staff will be informed if change in diet will be needed. Resident 1 has no dentures. Resident 1 had an appointment with oral surgery provider, for extractions and denture impressions.Review of Facility Policy titled, Dental Services for Residents dated, 7/17/25 indicated, .3. Emergency Dental Care: b. The Home will provide or make arrangement for the transportation of the Resident. c. Those Residents who have lost or damaged dentures will be promptly referred to a dentist within three days. During an interview on 9/1/25 at 11:00 a.m., with the Standards and Quality Manager (SCM), SCM stated, the above policy was reviewed with no revisions made on 7/17/25. SCM stated, the previous policy and procedure would have been the same.

Based on observation, interview and record review, the facility failed to develop and implement a resident centered comprehensive care plan with interventions for resident preferences including to be left alone in the shower room and aiding with showering, to meet the needs of one of three sampled residents, Resident 1. This failure resulted in Resident 1's unsupervised fall, fractured breastbone, breastbone bruise, fractures of thoracic spine (the mid-back section of the spine), scalp bruise and 2-day hospital stay. Findings: Resident 1 was a [AGE] year-old female admitted to the skilled nursing facility on 3/18/25, with a history of legal blindness and severe osteoarthritis (degeneration of joint cartilage and the underlying bone, causes pain and stiffness, especially in the hip, knee, and thumb joints. During an observation and interview on 4/22/25 at 2:40 p.m. Resident 1 was observed in bed laying face up, and stated she recalled the fall event on 4/15/25. Resident 1 stated she was legally blind but could see peripherally (the ability to see things to the side). Resident 1 stated she was alone in the shower, with the nursing assistant was outside the bathroom door when she lost balance, yelled out and fell . Resident 1 stated she suffered a bump on her head, hurt her neck and went out to the hospital emergency department after her fall. During an interview on 4/23/25 at 12:00 p.m. with Registered Nurse 3 (RN3), RN3 stated, on 4/15/25 at approximately 10:10 a.m. she responded to Resident 1's bathroom and found Resident 1 with a Certified Nurse's Aide (CNA1) sitting on the floor in the bathroom after a fall. RN3 further stated she assessed Resident 1 and notified Resident 1's doctor and family of the fall. RN3 stated Resident 1 initially denied pain but minutes later, started complaining of pain to her shoulder. RN3 stated the doctor ordered Resident 1 to go to the hospital emergency department for further evaluation. RN3 stated Resident 1 was legally blind and the fall could have been avoided if CNA1 had stayed in the shower and assisted Resident 1 with showering. During an interview on 4/23/25 at 3:02 p.m. with CNA1, she stated on 4/15/25 she assisted Resident 1 with shower preparation. CNA1 stated she waited outside the bathroom while Resident 1 showered. CNA1 further stated approximately 3 minutes later, she heard a yell and a boom from inside the bathroom. CNA1 stated she found Resident 1 laying on the bathroom floor halfway out of the shower. CNA1 stated this fall could have been avoided if someone was with Resident 1 to help during her shower. Review of Resident 1's admission History and Physical dated 3/18/25 indicated Resident 1 was a [AGE] year-old female with a history of blindness and severe osteoarthritis (OA), independent for her activities of daily living (ADL), however, her function level decreased to the point where she required more assistance with her ADLs. Review of Resident 1's care plan dated 3/18/25, indicated Resident 1 had a high risk for fall with injury, a history of falls, unsteady gait, poor vision and was prescribed opioid (medication used to reduce moderate to severe pain), hypnotic (medication tending to produce sleep), and diuretic (drugs that increase urine output, leading to the removal of excess water and salt from the body) medication. Review of Resident 1's fall risk assessment dated [DATE] indicated, Vision status: legally blind. Gait and balance: required use of assistive devices. Resident 1 was assessed as at high risk for fall. Review of Resident 1's resident assessment instrument/ minimum data set (RAI / MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) Section GG: functional abilities-admission (self-care) dated 3/25/25 indicated, admission performance: E. Shower and bathe self: Resident 1 required supervision or touching assistance, helper provide verbal cues, steadying, contact guard assistance (caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task) as resident completed activity . Review of Resident 1's care plan dated 3/26/25 10:02 a.m. indicated, problem: at risk for falls related to, limited mobility due to severe macular degeneration with poor vision, unsteady gait, chronic pain, numbness of fingers/foot (right), occasional bladder incontinent, taking hypnotics/diuretic/opioid/ medications, diagnosis of osteoporosis/ Cervical compression fracture (one or more of the vertebrae in the spine collapses or breaks). Goals: resident will demonstrate the ability to ambulate/transfer without fall related injuries. Resident 1's care plan did not contain interventions addressing resident preferences including to be left alone in the shower room, assistance with showering, or refusal of supervision while in the shower room. Review of Resident 1's nurse note dated 4/15/25 at 1:06 p.m. indicated, unwitnessed fall without injury. At about 10:10 a.m., was notified that Resident 1 had a fall in the bathroom, on getting there 3 staff were assisting her already and she was noted sitting in the shower. Resident was still alert and verbally responsive, was able to narrate what happened, she said that she had just finished her shower and was trying to wear her robe when she lost her balance and fell on the bathroom floor, hit her back on the floor. Review of Resident 1's History and Physical dated 4/18/25 indicated, hospitalization : 4/15/25-4/17/25 Readmission Diagnosis: status post fall with acute (sudden) manubrial (breastbone) fracture with parasternal hematoma (breastbone bruise), multiple thoracic (mid back) fractures, scalp contusion (bruising). Patient endorses prior history of thoracic spine compression fractures. Also has prior history of left arm injury with resultant weakness . Review of facility policy and procedure titled, Accident / Fall Prevention dated, 5/30/24 indicated, The Home will routinely assess each Skilled Nursing Facility (SNF) Resident for risk of accidents and implement preventive measures to decrease modifiable risks, as able. If an incident occurs, pertinent data will be collected, appropriate care will be provided, and the preventive measures will be re-evaluated in attempt to provide the safest environment possible. A. Evaluation Frequency: Residents are minimally evaluated for risk of accidents or falls: 1. Upon admission, 2. Quarterly, 3. Annually, 4. As needed (PRN); after each fall, incident, or change of condition. Evaluation methods and prevention planning may include: 1. Physician Assessment, 2. The Fall Risk Assessment 3. RAI/MDS - Assessment Tool . Review of facility policy and procedure titled, Care Plans dated, 2/13/25 indicated, I. Resident Assessments & Care Plans A. The Resident Assessment Instrument. Minimum Data Set (RAI/MDS) is completed as the basis for care plan decision-making at the skilled nursing facility (SNF) levels of care. B. All components of the care plan must be individualized for the Resident. Baseline Care Plan A. The facility must develop and implement a baseline care plan for each Resident within 48 hours upon admission that includes the instructions needed to provide effective and person-centered care of the Resident. B. The baseline care plan must reflect the Resident's stated goals and objectives and include interventions that address his/her current needs .Comprehensive Care Plan: A. The facility must develop and implement a comprehensive person-centered care plan for each Resident, consist with the Resident rights and includes measurable objectives and timeframes to meet a Resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .O. The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team (IDT) within 7 days after each RAI/MDS assessment, including both the comprehensive and quarterly review RAI/MDS assessment.

Based on interview and record review, the facility failed to ensure multiple allegations of sexual abuse involving residents diagnosed with dementia were reported to the required authorities when: 1. The facility did not notify local law enforcement, the Ombudsman (independent advocate who protects the rights and ensures the well-being of patients in long-term care facilities), the state survey agency (CDPH, California Department of Public Health), and the facility's Administrator (ADMIN) immediately, but not later than 2 hours after the allegation was made, when one of five sampled residents (Resident 1) reported an allegation of rape. 2. The facility did not notify the state survey agency (CDPH, California Department of Public Health) immediately, but not later than 2 hours after the allegation was made, when one of five sampled residents (Resident 1) was sexually abused by Resident 2 in the common area, witnessed by staff. These findings resulted in the delay of the investigation process by local law enforcement, Ombudsman, and state survey agency and can result in the potential for all allegations of abuse involving residents with dementia to not be identified, investigated, and prevented from recurrence. Additionally, these findings had the potential to result in leaving all residents unprotected from abuse. The facility census was 141. Findings: 1. During a review of Resident 1's Face Sheet (demographics), dated 4/8/2025, the Face Sheet indicated Resident 1 was admitted with diagnoses including unspecified dementia (decline in mental ability) with behavioral disturbances (persistent and/or repetitive behaviors that differ significantly from social norms) and psychotic symptoms (psychotic symptoms such as delusions [a persistent, false belief held with absolute certainty despite evidence]). During an interview on 4/8/2025 at 4:27 PM with the Therapeutic Activities Staff ([NAME]), the [NAME] stated on the morning of 3/26/2025, Resident 1 verbalized being raped while out at [medical facility name]. The [NAME] stated Resident 1 verbalized that while she was unconscious at [medical facility name], she would get raped. The [NAME] stated he reported it to the Social Worker (SW) on 3/26/2025 and denied reporting it as an abuse allegation to the ombudsman, local law enforcement, and CDPH. During a concurrent interview and record review on 4/8/2025 at 4:59 PM with the SW, Resident 1's Clinical Notes, dated 3/26/2025 were reviewed. The note indicated, SW was informed by [[NAME]] that [Resident 1] has been verbalizing delusion of being pregnant recently, as well as making accusations of rape while at [medical facility name] for treatment. The SW stated Resident 1 did not bring up the rape allegation when the SW checked in with Resident 1. The SW stated she did not think the report from Resident 1 counted as an abuse allegation, so she did not fill out an SOC 341 (official state form used to report suspected dependent adult/elder abuse form). The SW confirmed she was made aware of the allegation on 3/26/2025 and that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/8/2025 at 5:28 PM with the Supervising Registered Nurse (SRN), the SRN stated Resident 1 had paranoid behavior (irrational and excessive distrust and suspicion of others, often with the belief that they are trying to harm or deceive them) and delusional thinking. The SRN stated Resident 1's accusations was not new behavior, but confirmed it was the first time Resident 1 reported being raped. The SRN stated if she had felt it was really true and that Resident 1 had really been raped, she would have reported it right away. The SRN confirmed that she did not report it as an abuse allegation to local law enforcement, the Ombudsman, CDPH, and the ADMIN. During an interview on 4/9/2025 at 8:44 AM with the Ombudsman, the Ombudsman confirmed she did not receive an SOC 341 or any type of verbal or written report regarding Resident 1 alleging being raped at [medical facility name]. During an interview on 4/9/2025 at 2:06 PM with the Director of Nursing (DON), the DON stated staff had to have reasonable suspicion before reporting. The DON stated, If an alert and oriented resident claimed rape at an outside hospital, I would have reported it right away. The DON stated staff had to take Resident 1's mental condition into account to determine reasonable suspicion. During an interview on 4/9/2025 at 3:44 PM with the Staff Nurse Instructor (NI), the NI stated staff needed to consider for dementia patients if there's a history of unfounded claims. The NI stated that for a resident with full capacity, a SOC 341 would be filled out and reported, but for a resident with dementia, it would be hard to know whether this really happened and you don't want to get somebody in trouble. During an interview on 4/9/2025 at 4:20 PM with the Nurse Practitioner (NP), the NP stated she evaluated Resident 1 on 3/26/2025 due to Resident 1's allegation of rape and determined it to be a delusion. The NP confirmed that she did not fill out an SOC 341 and report it as an abuse allegation to anyone. During a review of Resident 1's Clinical Notes, dated 3/26/2025, the note indicated, Resident 1 has been verbalizing delusion of being pregnant recently, as well as making accusations of rape while at [medical facility name] for treatment. The note also indicated, the NP visited the resident, she was walking in the hallway with her walker. When the [NP] asked [Resident 1] how is she doing. [Resident 1] appeared very paranoid and stated that some guys are after her. [Resident 1] became tearful and walked away, she did not want to engage. During a concurrent interview and record review on 4/10/2025 at 9:25 AM with the ADMIN, the facility's policy & procedure (P&P) titled, Elder Abuse Prevention and Response, dated 5/1/2024 was reviewed. The P&P indicated, Any mandated reporter, who, . is told by an elder or dependent adult that he/she has experienced behavior constituting abuse . shall report the known or suspected instances of abuse immediately. The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN stated that he was not notified of every instance of abuse, and sometimes only found out abuse occurred once investigators were onsite. The ADMIN stated the staff needed to make sure the allegation was credible by investigation before reporting because Resident 1 had dementia with a history of delusions about being pregnant. The ADMIN was unable to provide documented evidence that he was notified of the allegation of rape made on 3/26/2025 within 2 hours after it was reported to staff. 2. During a review of Resident 1's Face Sheet (demographics), dated 4/8/2025, the Face Sheet indicated Resident 1 was admitted with diagnoses including unspecified dementia (decline in mental ability) with behavioral disturbances (persistent and/or repetitive behaviors that differ significantly from social norms) and severe recurrent major depressive disorder with psychotic symptoms (severe form of depression where a person experiences symptoms of major depression and psychotic symptoms such as delusions). During a review of Resident 2's Face Sheet (demographics), dated 4/8/2025, the Face Sheet indicated Resident 2 was admitted with a diagnosis of unspecified dementia with behavioral disturbances. During a review of Resident 1's Clinical Notes, dated 4/4/2025, the notes indicated, the Registered Nurse (RN) was notified on 4/4/2025 at approximately 1405 .by the activity staff and CNA that [Resident 1] was witnessed being sexually abused by [Resident 2] during activity in the common area. During an interview on 4/8/2025 at 11:14 AM with the RN. The RN stated she reported the incident to the Ombudsman and to local law enforcement on 4/4/2025 but not to CDPH because the facility trained the staff that reporting abuse to CDPH was not required when the abuse was caused by a resident with dementia and if there was no serious bodily injury. During an interview on 4/9/2025 at 9:51 AM with the Activities Coordinator (AC), the AC stated that on 4/4/2025, she witnessed Resident 2 was walking through the common area and stopped behind Resident 1 who was seated in a chair. The AC stated she witnessed Resident 2 lean down forward to kiss Resident 1, Resident 1 tried to move her head away, and Resident 2 ended up kissing Resident 1 on the right side of the face. During an interview on 4/9/2025 at 10:16 AM with the Certified Nursing Assistant (CNA), the CNA stated that on 4/4/2025 she was alerted by the AC that Resident 2 kissed Resident 1 and when she tried to redirect Resident 2 away from Resident 1, she witnessed Resident 2 grab Resident 1's right breast. During an interview on 4/9/2025 at 11:06 AM with the Supervising Registered Nurse (SRN), the SRN stated Resident 1 was not capable of consenting to a kiss or touch because she was very confused and has dementia. The SRN stated the incident counted as sexual abuse. The SRN confirmed the RN reported the sexual abuse to the Ombudsman and law enforcement on 4/4/2025, but not to CDPH. During a concurrent interview and record review on 4/10/2025 at 9:24 AM with the facility's Administrator (ADMIN), the facility's procedure form titled, Mandated Reporter [undated], was reviewed. The form indicated the facility's protocol for abuse reporting did not conform with the federal requirement to report allegations of abuse to the state survey agency, CDPH. The form indicated abuse incidents caused by a resident diagnosed with dementia and did not result in serious bodily injury did not need to be reported to CDPH. The ADMIN stated he was the abuse coordinator (responsible for ensuring staff are trained adequately regarding abuse prevention and reporting) for the facility. The ADMIN confirmed the facility's practice and staff training included not reporting to CDPH if the incident was caused by resident diagnosed with dementia and there were no serious bodily injury. During a review of the facility's policy & procedure (P&P) titled, Elder Abuse Prevention and Response, dated 5/1/2024, the P&P indicated, Any mandated reporter, who, . is told by an elder or dependent adult that he/she has experienced behavior constituting abuse . shall report the known or suspected instances of abuse immediately.

50669 Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Two kitchen staffs did not wear hair restraints while in the kitchen. 2. Two of three ice machines were dirty. 3. Three of three water filters for the ice machine were expired. 4. Two of three dishwashers did not reach minimum temperature for wash cycle. 5. One bottle of expired rice wine vinegar in dry storage. 6. One kitchen staff did not wash hands between handling dirty to clean dishes These failures posed the risk for food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile resident population of 144 facility residents who received food prepared in the kitchen. Findings: 1a. During an observation on [DATE] at 11:26 a.m. in the Main Kitchen, Food Service Technician (FST) 6 entered kitchen without hair net and took prepared meal trays from the [brand name] food warmer labeled SNF (skilled nursing facility) C2. During an interview on [DATE] at 11:46 a.m. with the Food Service Supervisor (FSS), the FSS stated hairnets are to be worn at all times in the kitchen. During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated [DATE], the P&P indicated, . Hairnets shall be worn before entering the kitchen to prevent food contamination from falling hair . 1b. During a concurrent observation and interview on [DATE] at 11:46 a.m. with the Food Service Supervisor (FSS) in the B307-Food Prep satellite kitchen, Food Service Technician (FST) 7 was not wearing a hair restraint. The FSS stated beard covers are necessary and yes he needs one. During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated [DATE], the P&P indicated, Hairnets shall be worn before entering the kitchen to prevent food contamination from falling hair . 2a. During a concurrent observation and interview on [DATE] at 9:22 a.m. with the Chief Engineer (CE) in Unit C3-common area, the CE instructed the Maintenance Engineer (ME) to take apart the [brand name] ice machine to visualize cleanliness. Observed ice shoot with thick white build up, metal grill and drain pan were visually dirty with unknown brown substance, and when the inside of the water dispenser tubing was wiped with paper towel there was an unknown pink and brown residue. The CE confirmed [brand name] ice machine was dirty and instructed the ME to notify nursing staff, the ice machine was out of use until it was properly cleaned. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and Maintenance Policy, dated [DATE], the P&P indicated, The [facility name] is responsible for cleaning, sanitizing and maintaining all ice machines in the licensed care area and in the kitchens every 3 months, and as needed . 2b. During a concurrent observation and interview on [DATE] at 9:53 a.m. with the Maintenance Engineer (ME) in Unit C2-common area, the ME took apart the [brand name] ice machine to visualize cleanliness. Observed ice shoot with thick white build up, and when the inside of the water dispenser tubing was wiped with paper towel there was an unknown pink and brown residue. The ME stated that is dirty. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and Maintenance Policy, dated [DATE], the P&P indicated, The [facility name] is responsible for cleaning, sanitizing and maintaining all ice machines in the licensed care area and in the kitchens every 3 months, and as needed . 3. During an observation on [DATE] at 10:02 a.m. in the Main Kitchen, three [brand name] water filters for the ice machine had an expiration date of [DATE]. During an interview on [DATE] at 3:29 p.m. with the Maintenance Engineer (ME), the ME stated the maintenance for the water filters were annual and it was a hiccup. It got missed. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning, Sanitation and Maintenance Policy, dated [DATE], the P&P indicated, The water filters will be changed annually or as needed . 4. During an observation on [DATE] at 11:39 a.m. in the B307-Food Prep satellite kitchen, the [brand name] dishwasher highest temperature, during wash cycle, was 147 degrees Fahrenheit. During a concurrent observation and interview on [DATE] at 10:04 a.m. with FST 2 in the B207-Food Prep satellite kitchen, [brand name] dishwasher completed a wash cycle and temperature read below 150 degrees Fahrenheit. FST 2 confirmed wash cycle temperature read below 150 degrees Fahrenheit and stated he was unsure if the wash temperature needed to maintain 150 degrees Fahrenheit. During an interview on [DATE] at 2:35 p.m. with the Chief of Plant Operations (CPO), the CPO confirmed plant operation department is responsible for maintenance of [brand name] dishwashers and stated, No, that's not normal. The CPO stated staff need to give one minute between wash cycles to ensure dishwasher temperature has enough time to rise after each cycle. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Warewashing Manual & Mechanical, dated [DATE], the P&P indicated, DISH MACHINES . Wash temperature will be between ,d+[DATE] degree Fahrenheit . 5. During an observation on [DATE] at 11:09 a.m. in the Main Kitchen, there was one bottle of rice wine vinegar with a use by date of [DATE]. During an interview on [DATE] at 11:11 a.m. the [NAME] Specialist (CS) 2, the CS 2 confirmed rice wine vinegar was expired and stated, No, we need to throw this away. During a review U.S [United States] Food and Drug Administration (FDA) Food Code dated 2022, the U.S FDA Food Code indicated, . foods that exceed the use-by date . must be disposed of . 6. During a concurrent observation and interview on [DATE] at 10:33 a.m. with Food Service Technician (FST) 8 in the Main Kitchen, FST 8 was washing dishes with yellow rubber gloves overtop of blue disposable gloves. FST 8 removed the yellow rubber gloves and kept the blue disposable gloves on and picked up clean dishes. FST 8 stated she did not need to wash her hands because she wore two pairs of gloves. During an interview on [DATE] at 8:44 a.m. the Assistant Director of Dietetic (ADD), the ADD stated the expectation is for staff to take off both pairs of gloves and wash their hands between handling dirty and clean dishes. During a review of the facility's policy and procedure (P&P) titled, Dietary Services, Infection Control, dated [DATE], the P&P indicated, Proper hand washing shall be done . after removing gloves .

Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) committee failed to identify, prioritize, and address the staffing need for a Director of Dietetics to provide qualified oversight of all kitchen services. These failures resulted in compromising food safety and the potential to cause severe food borne illnesses and injuries in a medically fragile population of 144 residents. (Refer to F802, F805, F812) Findings: During a concurrent interview and record review on 12/6/24 at 10:00 a.m. with QAPI representatives including the Director of Nursing (DON) and the Standards and Compliance Manager (SCM), the QAPI Meeting Minutes, dated January to November 2024 were reviewed. The minutes indicated no focus on meeting the staffing need for a Director of Dietetics that would provide qualified oversight over dietary staff to deliver safe and sanitary food service and ensure kitchen staff was competent in performing their job duties safely and effectively. The DON and SCM confirmed the vacancy for a Director of Dietetics was not focused on as a staffing need during QAPI. During an interview on 12/6/24 at 10:44 a.m. with QAPI representatives including the DON, the SCM, and the Administrator (ADMIN), the ADMIN stated the current ADD was the defacto (default) person overseeing dietary services alongside two Food Service Managers. During a review of the QAPI Meeting Minutes, dated January to November 2024, the minutes indicated no mention of unmet kitchen staff competency evaluations being identified and addressed. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Plan, undated, the P&P indicated, The purpose of QAPI in our organization is to ensure that residents of [facility name] are provided a high quality of care and services through multi-disciplinary oversight and that regulatory and corporate compliance is achieved through the application of a systematic and comprehensive quality management approach.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when kitchen staff were unable to effectively operate the dishwasher in the satellite kitchens, B207-Food Prep and B307-Food Prep. This failure had the potential for residents to be served food on unclean dishes and result in food borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 118 residents. Findings: During an observation on 12/2/24 at 11:39 a.m. in the B307-Food Prep satellite kitchen, the highest temperature the [brand name] dishwasher, a high temperature dishwasher (dishwasher that used high temperatures to clean and sanitize), reached during wash cycle was 148 degrees Fahrenheit (unit of measurement). During an interview on 12/2/24 at 11:41 a.m. with Food Service Technician (FST) 1, FST 1 stated he did not know if the dishwasher needed to maintain a minimum temperature of 150 degrees Fahrenheit during the wash cycle. During an interview on 12/2/24 at 11:46 a.m. with the Food Service Supervisor (FSS), the FSS stated it was normal for the dishwasher to not stay at 150 degrees Fahrenheit during the wash cycle, and it did not need to. During a concurrent observation and interview on 12/3/24 at 10:04 a.m. with FST 2 in the B207-Food Prep satellite kitchen, the [brand name] dishwasher completed a wash cycle and temperature read below 150 degrees Fahrenheit. FST 2 confirmed the wash cycle temperature read below 150 degrees Fahrenheit and stated he was unsure if the wash temperature needed to maintain 150 degrees Fahrenheit the entire time. During an interview on 12/3/24 at 2:35 p.m. with the Chief of Plant Operations (CPO), the CPO confirmed the Plant Operation Department was responsible for maintenance of [brand name] dishwashers and stated it was not normal for the [brand name] dishwasher to not maintain a temperature of 150 degrees Fahrenheit during the entire wash cycle. The CPO stated staff needed to give one minute between wash cycles to ensure dishwasher temperature had enough time to rise after each wash cycle. During an interview on 12/5/24 at 4:18 p.m. with the FSS, the FSS stated she did not get any formal training on the dishwashers. The FSS stated she observed others operating the dishwasher. The FSS stated that staff could go back-to-back washing multiple loads of dishes. During an interview on 12/5/24 at 1:38 p.m. with the Food Manager (FM), the FM stated he did not know if kitchen staff were trained on how to use the [brand name] dishwashers. During an interview on 12/5/24 at 2:34 p.m. with the Assistant Director of Dietetics (ADD), the ADD stated she never received training on how to use the [brand name] dishwashers and the Food Service Supervisors were responsible for training staff. The ADD further stated she did not oversee the Food Services Department which referred kitchen staff. The ADD stated she only oversaw the Dietetic Department which referred only to the Registered Dieticians. During a review of FST 1's Duty Statement, dated 4/8/24, the Duty Statement indicated, ESSENTIAL FUNCTIONS . operate dish washing machines . During a review of FST4's Food and Nutrition Services: Competency Checklist, dated 5/14/24, the Food and Nutrition Services: Competency Checklist indicated FST 4 was not evaluated on the ability to state proper procedure of testing dish machine. During a review of FST3's Food and Nutrition Services: Competency Checklist, dated 5/14/24, the Food and Nutrition Services: Competency Checklist indicated, FST 3 was evaluated on the ability to state proper procedure of testing dish machine and Not Met was checked. During a review of the FSS's Duty Statement, dated 5/1/24, the Duty Statement indicated, ESSENTIAL FUNCTIONS . organize, supervise, and lead . proper maintenance of equipment . identify training needs of employees and conduct in-service training . During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services- Warewashing Manual & Mechanical, dated 6/14/24, the P&P indicated, The Food & Nutrition Services Director or designee is responsible for the training of employees in procedures . DISH MACHINES . Wash temperature will be between 150-160 degree Fahrenheit .