Every finding on record at Vibra Hospital of Northern California D/P SNF

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Time/Temperature Control for Safey (TCS) food, (food that requires specific temperature management to prevent harmful bacteria growth and toxin formation), for residents was not stored at appropriate temperatures in one of one nourishment refrigerators; and 2. The dish machine wash and rinse cycle temperatures did not meet manufacturer's temperature specifications; and 3. Black matter was found on the underside of the top surface of the ice machine storage bin located in the facility kitchen; and 4. A butcher block wooden cutting board was not cleaned with soap and water before being sanitized; and 5. [NAME] discoloration was found on the blending blades of two food processors in the kitchen; and 6. One plastic cutting board and three plastic bowls used for food preparation and food service showed signs of excessive wear. These failures had the potential to cause foodborne illnesses in 30 out of 30 residents who consumed food prepared in the facility's kitchen. Findings: A review of the facility's, Matrix dated 5/20/25, indicated there were 30 residents residing in the facility who received food prepared in the kitchen. 1. A review of a US Food and Drug Administration (USDA) Refrigerator and Freezer Storage Chart, dated 03/2018, indicated that keeping refrigerated TCS food at 40 degrees Fahrenheit (F, a unit of temperature measure), or less helps keep foods from spoiling or becoming dangerous. A review of a facility's, Food and Nutrition Services policy titled, Physical Plant and Equipment - Department Security, rev. 08/2024, indicated that Food and Nutrition Services were to maintain sufficient space, equipment, supplies and processes to provide for the safe, efficient and sanitary production and provision of food services to patients, including perishable foods being stored at proper temperatures. During an observation made on 5/20/25 at 3:08 pm, of the nourishment refrigerator used to store snacks for facility residents and food brought from the outside located in the residential dining room, it was noted the internal section of the refrigerator felt warmer than expected; a sensor device used to monitor the refrigerator temperature was observed, however, no readable thermometers were visible in the refrigerator. During an interview on 5/20/25 at 3:18 pm, the Director of Plant Operations (DPO) stated that all refrigerator temperatures were monitored remotely and if the range was out of normal for more than an hour, the DPO and the Dietary Manager (DM) were notified. During an interview on 5/20/25 at 3:25 pm, DM confirmed he received an alert if the refrigerator temperatures were two degrees over set parameters but did not know the temperature set-points, and stated he would like a back-up thermometer in the nourishment refrigerator. During an interview on 5/20/25 at 3:34 pm, DPO stated that the maximum temperature for the nourishment refrigerator was set at 46 degrees F. DPO added the nourishment refrigerator temperature range had been at that range for years and he was not sure what the proper temperature range for perishable food items should be. During an interview on 5/20/25 at 3:37 pm, DM confirmed that the refrigerator temperature should be less than 41 degrees F. During an observation of the nourishment refrigerator in the residential dining room on 5/20/25 at 4:22 pm, food temperatures were checked with a thermometer; the internal temperature of string cheese was 46.2 degrees F, and the internal temperature of cheddar cheese was 48 degrees F. During an interview on 5/20/25 at 4:33 pm, DM stated he would discard the cheese stored in the nourishment refrigerator. During an interview on 5/22/25 at 9:10 am, the Registered Dietician (RD) confirmed that the nourishment refrigerator temperatures were monitored online and that she does not inspect the nourishment refrigerators. A record review made of the nourishment refrigerator temperature graphs, dated 5/13/25 through 5/20/25, indicated the temperature peaked at or above 41 degrees F on 30 separate occasions. 2. A review of a facility Food and Nutrition Services policy titled, Dishwashing, Pot Washing, rev. 01/2023, indicated the automatic dish machine operations are maintained to ensure that dishes, pots and pans are clean, sanitized and dry before returning to service and temperatures for chemical sanitizing machines should be 120 degrees F, or higher, for both wash and final rinse cycles. During a concurrent observation and interview on 5/20/25 at 10:25 am, with [NAME] C and the DM present, [NAME] C was observed loading the automatic dish machine. The temperature gauge registered 100 degrees F for the wash cycle and 110 degrees F for the rinse cycle; when asked the expected temperature of the wash and rinse cycles, [NAME] C stated 120 degrees F. Another wash cycle was observed and the dish machine temperature reached 108 degrees F; on a third observation the wash cycle temperature reached 120 degrees F, and the rinse cycle 117 degrees F. [NAME] C stated he runs the dish machine four times to get the water hot. At 10:47 am, the automatic dish machine temperatures were rechecked two more times; the wash cycle registered 110 degrees F, the rinse cycle 116 degrees F, and the wash cycle 110 degrees F and the rinse cycle 118 degrees F on the second check. The DM confirmed the findings. A review of the manufacturer's signage plate on the dishwasher titled, NSF Machine Operation Requirements indicated wash and rinse water temperatures were required to be at 120 degrees F at minimum. 3. A review of the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to the sight and touch. A review of Follet manufacture's procedural, untitled, undated, on maintenance and cleaning of the ice making machine, indicated that sanitizing solution was to be wiped on the interior of the ice storage area. During a concurrent observation and interview with the DPO on 5/21/25 at 9 am, the underside of the interior ice storage compartment was wiped with a white cloth; a black substance was evident on the cloth and shown to DPO who confirmed the finding and stated he cleaned the internal components, and the DM cleaned the ice storage bin. During an interview on 5/21/25 at 9:30 am, DM confirmed the finding and stated he wiped down the sides and back of the ice storage bin but not the underside of the top near the dispensing chute as the DPO cleaned that part. During an interview on 5/22/25 at 9:10 am, the RD stated the ice machine should be cleaned according to the manufacturer guidelines. 4. A review of a facility's policy titled, Cleaning and Conditioning of Butcher Block Cutting Board in Cafe, undated, indicated that the butcher block was to be cleaned with hot soapy water and a clean towel, then rinsed with hot water, and wiped with sanitizing solution after each meal or use. During an observation of the lunch meal tray line in the facility cafe on 5/21/25 at 11:00 am, [NAME] D sliced pork and fish on a wooden butcher block. After the lunch meal tray line was finished, at 12:15 pm, the butcher block and steam table had bits of food and juices. [NAME] D used a sanitizing solution and a cloth to wipe down the butcher block cutting board and steam table surfaces. He was not observed to use soap and water. During an interview on 5/21/25 at 3:22 pm, the DM stated that [NAME] D should wash the butcher block with soap and water, rinse and then sanitize and that it was not alright to sanitize only. 5. A review of the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils (A) Equipment, food-contact surfaces and utensils shall be clean to the sight and touch. A review of a facility's, Food and Nutrition Services policy titled, Physical Plant and Equipment - Department Security, rev 08/2024, indicated that Food and Nutrition Services were to maintain sufficient space, equipment, supplies and processes to provide for the safe, efficient and sanitary production and provision of food services to patients. During a concurrent observation of the kitchen and interview with the DM on 5/20/25 at 9:22 am, brown discolorations were observed on the cutting blades of two [Robot Coupe] food processors. DM confirmed the findings and stated the blades were less than a year old, and he would order replacements. 6. A review of a facility's, Food and Nutrition Services policy titled, Physical Plant and Equipment - Department Security, rev 08/2024, indicated that all serving ware that have lost their glaze or are otherwise damaged are to be discarded. During a concurrent observation of the kitchen and interview with the DM on 5/20/25 at 9:22 am, excessive wear was found on three food bowls and a plastic cutting board; the finding was confirmed by DM who removed the items from circulation.

Based on interview and record review the facility failed to ensure a copy of the discharge notice was sent to the Office of the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) for two out of three sampled residents (Residents 14 and 16). This failure had the potential to violate the resident right to appeal their discharge. Findings: A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Nursing Services, dated, 1/1/24, indicated, when the residents were discharged from the facility, the residents would be notified in writing. The P&P indicated, The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. A review of the, Clinical Record Abstract, dated 5/21/25, indicated, Resident 14 was admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus (uncontrolled blood sugar levels) with diabetic chronic kidney disease (an organ that filtered out the body's waste, became damaged due to uncontrolled blood sugar). Resident 14 was transferred to the hospital and discharged from the facility on 3/25/25. A review of the, Clinical Record Abstract, dated 5/21/25, indicated, Resident 16 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (breathing problems that worsen over time). Resident 16 left the facility against medical advice (AMA) and was discharged from the facility on 4/9/25. During an interview on 5/21/25 at 3:30 pm, Case Manager (CM) confirmed, Resident 14 was transferred to the hospital on 3/25/25 and Resident 16 left the facility AMA on 4/9/25. CM stated, we haven't been doing the notification to Ombudsman for transfer to hospitals or for residents who leave AMA. During an interview on 5/21/25 at 3:44 pm, Director of Nursing confirmed the notification of discharge for Residents 14 and 16 had not been sent to the Ombudsman office.

Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance with manufacturer's instructions and accepted standards of clinical practice for 3 of 31 medication administration opportunities observed, resulting in a medication error rate of 9.7%. This failure placed residents at risk of reduced therapeutic effect and potential harm. Findings: Review of Resident 217's record titled, Discharge Reconciliation Report, dated 5/21/2025, indicated Resident 217 had an order for MiraLAX; 1 packet (medication used for constipation) daily and Trelegy Ellipta inhaler (used to treat asthma and the management of chronic obstructive pulmonary disease) 1 puff daily. The instructions were to breathe out slowly and then fully inhale the dose while taking a slow deep breath through the mouth and hold breath for 10 seconds or as long as long as comfortable, then breathe out slowly. During an observation at 8:25 am, in Resident 217's room, Licensed Nurse (LN) A was preparing Resident 217's morning medications. LN A mixed the MiraLAX in approximately 8 ounces of fluid. Resident 217 drank about half the solution and placed the glass with the remaining liquid on the bedside table. LN A made no effort to prompt Resident 217 to complete the dose or remove the medication before leaving the room. Review of the manufacturer's directions for MiraLAX, dated 12/2024, indicated the full contents of the dissolved powder must be ingested to ensure effectiveness. The manufacturer of MiraLAX specifically instructs that it should be mixed with 4-8 ounces of a liquid (such as water, juice, or tea) and consumed immediately. The product is not intended to sit for long periods after mixing. If it is mixed and left out, it may change in consistency or texture, which could increase the risk of choking, especially in older adults or residents with swallowing difficulties (dysphagia). Review of the facility's policy titled, Medication Management; Administrations of Medications, dated 10/2024, indicated prepared medications may never be left unattended at the patient's bedside without a licensed practitioner's order. During a review of Resident 13's record titled, Orders, dated 5/16/2025, indicated Resident 13 had an order for Lovenox (medication used to thin the blood) 40 milligrams (mg, a unit of measure), to be given subcutaneously (under the skin), every day for blood clot prevention. The order indicated in capital letters, ROTATE INJECTION SITES. During a medication pass observation on 5/21/2025 at 9:00 am, in Resident 13's room, LN B administered Lovenox subcutaneously into the right lower abdomen. The injection was clearly below the belly button on the lower right side. A review of Resident 13's Medication Administration Record (MAR), indicated the previous dose had also been given in the right lower abdomen, indicating the same site was used on consecutive days. LN B confirmed that she did not verify the prior injection site before administration. When asked about site rotation, LN B stated, I just asked the resident where she wanted it. A review of the manufacturer's insert for Lovenox (enoxaparin sodium) indicated that subcutaneous injections should be rotated to different areas of the abdomen to reduce the risk of local irritation or tissue damage. The manufacturer specifically stated: Administer Lovenox by deep subcutaneous injection in the abdominal area. Alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall (left and right upper and lower abdomen). This means that each dose should be given at a different site, rotating between the four recommended quadrants of the abdominal area to avoid repeated injections in the same spot.

Based on observation, interview and facility document review the facility failed to provide a meal substitute equivalent in nutritive value and food preferences were not honored when: 1. Two of two residents (Resident 367 and Resident 9), received a grilled cheese sandwich as a meal substitute for the lunch meal; and 2. Food preferences were not honored for one of one residents (Resident 7) These failures posed the risk for resident nutritional needs not being met which could lead to unplanned weight loss. Findings: 1. Review of the facility's document titled, Diet Spreadsheet dated 5/21/25, showed for the CCHO (carbohydrate controlled) diet and the Low Potassium (K) diet, the lunch meal entree was three ounces of pork roast. Review of the facility's document titled, Detailed Menu Nutritional Analysis for day four, menu cycle: Summer Menu showed three ounces of pork roast provided 23 grams (gms, a unit of measure) of protein and 173 kilocalories (calories). Review of the facility's document titled, Grilled Cheese Sandwich dated 5/22/25 directed, 1. Place three ounces of cheese between two slices of bread. Review of the nutrition facts of the American pasteurized process cheese used to make the grilled cheese sandwiches showed that two slices of cheese was equivalent to 28 gms, or one ounce, provided five gms of protein and 90 kilocalories which was 18 gms protein and 83 kilocalories less than the entree served. A medical record review for Resident 365 was initiated on 5/21/25. Resident 365 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a medical condition characterized by paralysis) following a cerebral infarction (ischemic stroke, when blood flow to the brain is blocked causing brain tissue to die). A CCHO (consistent carbohydrate) soft and bite-sized diet was ordered by the Physician on 1/28/25. During the lunch meal tray line observation on 5/21/25 at 11:30 am, Resident 365's lunch meal tray contained one grilled cheese sandwich and cooked beets. On 5/21/25 at 12:20 pm, an interview was conducted with [NAME] D. [NAME] D was asked to describe how he made a grilled cheese sandwich. [NAME] D stated he used two slices of American pasteurized process cheese and two slices of bread for the grilled cheese sandwich. On 5/22/25 at 9:10 am, an interview was conducted with the Registered Dietitian (RD). The RD confirmed a meal substitute should be equivalent in nutritive value as the entree served for that same meal. The RD confirmed the recipe for the grilled cheese sandwich called for three ounces of cheese, but six slices of American pasteurized process cheese should be used per sandwich. A Medical record review for Resident 9 was initiated on 5/21/25. Resident 9 was admitted to the facility on [DATE] with diagnoses including urinary tract infection and sepsis, a life-threatening complication of an infection. A low potassium diet was ordered by the Physician on 5/14/25. During the lunch meal tray line observation on 5/21/25 at 11:30 am, Resident 9's lunch meal tray contained one grilled cheese sandwich and cooked beets. On 5/21/25 at 12:20 pm, an interview was conducted with [NAME] D. [NAME] D was asked to describe how he made a grilled cheese sandwich. [NAME] D stated he used two slices of American pasteurized process cheese and two slices of bread for the grilled cheese sandwich. On 5/22/25 at 9:10 am, an interview was conducted with the RD. The RD confirmed a meal substitute should be equivalent in nutritive value as the entree served for that same meal. The RD confirmed the recipe for the grilled cheese sandwich called for three ounces of cheese, but six slices of American pasteurized process cheese should be used per sandwich. 2. A Medical record review for Resident 7 was initiated on 5/21/25. Resident 7 was admitted to the facility on [DATE] with diagnoses including syncope or fainting, and Diabetes Mellitus a condition in which the body has trouble controlling blood sugar. Review of the facility's document titled, Diet Spreadsheet dated 5/20/25, showed the vegetable for the lunch meal was yellow squash. Review of Resident 7's lunch meal ticket dated 5/20/25 showed Resident 7 disliked green beans, carrots, okra, green peas, squash and zucchini. During an observation and interview of the lunch meal on 5/20/25 at 11:58 am, Resident 7's lunch meal tray contained a vegetable mixture that included carrots, squash, and green beans. Resident 7 was asked about the vegetables on her plate, she stated she did not like the vegetables served and did not eat them. When asked how often she received food she didn't like, Resident 7 stated, This happens all the time, every day. On 5/21/25 at 12:23 pm, an interview was conducted the Menu Planner (MP). The MP stated the RD instructed her to serve a hot vegetable to all residents. On 5/21/25 at 5/22/25 at 9:10 am, an interview was conducted with the RD. The RD clarified it was not necessary to serve a hot vegetable to all residents and a salad would be fine to substitute if the resident did not like the hot vegetables. The RD added it was not necessary to serve both a salad and hot vegetables.

Based on observation, interview, and record review, the facility failed to follow their Self-Catheterization (a procedure where the resident inserts and removes a flexible tube into the bladder and drains urine without the assistance of staff), policy and procedure (P&P) for one of one sampled residents (Resident 13) when: 1. The facility did not maintain adequate self-catheterization supplies; and 2. There was no physician order for Resident 13 to perform self-catheterization; and 3. There was no nursing assessment performed to ensure Resident 13 was able to perform self-catheterization safely. This had the potential to damage the bladder, cause infection, and could cause psychosocial harm. Findings: 1. A review of the facility's P&P titled, Self-Catheterization revised 6/1/24, indicated, the facility would ensure residents that performed self-catheterization were provided with supplies and equipment. A review of the Clinical Record Abstract, dated 5/22/25, indicated, Resident 13 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease without dyskinesia, without mentation of fluctuation (a disease that caused uncontrolled body movements and these uncontrolled body movements were not present at this stage of the disease). A review of the admission Minimum Data Set (MDS, a resident assessment tool), dated 5/4/25, indicated, Resident 13 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 out of 15, indicating Resident 13's memory was intact. During a concurrent observation and interview on 5/20/25 at 2:39 pm, Resident 13 stated, I have asked for female self-catheterization kits, they only have male self-catheterization kits, and I just use what they give me. On a bedside table next to Resident 13's bed was a self-catheterization kit, and the label indicated, it was male cath-kit, 14.9 inches in length (Female self-catheterization tubes were approximately seven inches in length (sometimes shorter) and male self-catheterization tubes were approximately 15 inches in length (sometimes longer). When a female used the male self-catheterization tube, it placed them at a higher risk for infection or damage to the bladder). Resident 13 stated, it's frustrating that I don't have the right supplies. During a concurrent observation and interview on 5/22/25 at 9:05 am, with the facility's Infection Preventionist (IP), the central supply room, located at the nurse's station was observed. IP confirmed, there were no female self-catheterization kits present in the central supply room and stated, I didn't know there was a male or female straight cath [self-catheterization kit]. During an interview on 5/22/25 at 9:10 am, Materials Manager (MM) stated, we have never had any other straight cath than this and I didn't know there was a female one. MM confirmed that the facility did not provide Resident 13 with adequate supplies to perform self-catheterization safely. 2. A review of the facility's P&P titled, Self-Catheterization revised 6/1/24, indicated, Physician or NP (Nurse Practitioner) orders must confirm the resident is competent and appropriate for self-catheterization. During a concurrent interview and record review on 5/22/25 at 10:15 am, with Charge Nurse (CN), Resident 13's Orders were reviewed. CN stated, there was no order for [Resident 13] to perform self-catheterization. 3. A review of the facility's P&P titled, Self-Catheterization revised 6/1/24, indicated, residents would demonstrate self-catheterization and would be assessed to ensure the resident was competent and maintained a sterile technique (preventing contamination). A review of the, Plan of Care, dated 5/3/25, indicated, Resident 13 had difficulty with urinating, performed self-catheterizations, and would demonstrate knowledge of the bladder program. During a concurrent interview and record review on 5/22/25 at 10:15 am, CN reviewed nursing assessments dated 5/1/25 through 5/15/25 and stated, there were no self-catheterization assessments present in Resident 13's medical record. During an interview on 5/22/25 at 10:47 am, the Director of Nursing confirmed there was no physician's order for Resident 13 to perform self-catheterization and there was no assessment present indicating Resident 13 was able to perform self-catheterization safely.

Based on observation, interview and record review, the facility failed to ensure: 1. Metoprolol injectable vials (intravenous medication use to treat high blood pressure, and heart problems), were not stored and protected according to manufacturer recommendations for 1 of 1 pharmacy storage areas reviewed. 2. The nursing staff discarded MediSense (a brand name) glucose control solution (a solution with a specific known concentration of sugar used to calibrate and check the accuracy of a blood glucose meter) vials, when they expired. This failure had the potential to affect the stability and effectiveness of medications administered to residents and produced inaccurate patient blood glucose test results which could have led to negative clinical outcomes. Findings: 1. During an observation on [DATE] at 11:00 am, in the facility's pharmacy, three injectable vials of metoprolol were stored in a small container directly under an overhead light. The vials were not enclosed in an amber bag, or otherwise shielded from light. Review of the manufacturer's guidelines product insert for metoprolol under the heading titled, Supplied /Storage and Handling, dated [DATE], indicated metoprolol must be protected from heat and light to preserve its stability and potency. During an interview on [DATE] at 2:00 pm, with Director of Pharmacy (DOP), DOP confirmed the vials of metoprolol were not protected from light. DOP confirmed the vials should have been protected from light. Review of the facility's policy titled, Medication Management; Storage of Medications, dated ,d+[DATE], indicated medications must be stored under proper conditions of sanitation, light, humidity, ventilation, segregation and security as determined by the manufacturer's labeling. 2. During a concurrent observation and interview, on [DATE] at 8:35 am, in the medication room, with Assistant Director of Nursing (ADON), two MediSense glucose control vials, one labeled HI and one labeled LOW, had the manufacturer's printed expiration date of [DATE]. ADON confirmed the expiration date on the vials were [DATE], and should have been checked and discarded by the nursing staff. Review of the manufacturer's guideline for MediSense Glucose and Ketone Control Solutions, dated ,d+[DATE], under the heading of Storage and Handling, indicated, discard control solutions 3 months after opening or on the expiration date printed on the bottle, whichever comes first. Under the heading, Precautions and Warnings, indicated do not use control solutions if they are expired. Review of the facility's policy titled, Nursing; Fingerstick Blood Glucose, dated ,d+[DATE], indicated the meter will be cleaned, maintained and properly calibrated per manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to ensure dietary menus were followed when: 1. [NAME] D did not follow the puree pork recipe; and 2. [NAME] D did not consistently use the required scoop sizes when measuring portions of food. These failures had the potential for under or over nourishment resulting in poor health outcomes for 30 out of 30 residents who received food prepared in the facility kitchen. Findings: A review of the facility's Matrix dated 5/20/25, indicated there were 30 residents residing in the facility who received food prepared in the kitchen. 1. A review of a facility's, Food and Nutrition Services policy titled, Standardized Diets, rev. 01/2025, indicated that regular and therapeutic [specialized] diets are planned to guide patient menu processing, meal production, and preparation. A review of a facility production recipe, undated, for pureed (ground) pork roast specified three ounce servings of pork; the directions indicated that water or stock could be used in the preparation of the recipe, and that the sodium content of the recipe as prepared should be 52 milligrams (mg, a unit of measure). Nutritional analysis of the recipe was based on using water and if other liquid was used nutritional analysis will vary. During a concurrent observation and interview in the kitchen on 5/21/25 at 10:22 am, [NAME] D was observed to remove slices of pork from a covered container and confirmed the pork slices totalled four portions of meat, and pureed the meat in a Robot Coupe food processor. When asked if he had weighed the pork to determine the correct portions, [NAME] D replied that he had not, and had eye-balled the portion sizes. [NAME] D added 1 cup of regular chicken broth to the recipe, and when asked if the broth were low sodium (salt), he provided the box he used in preparing the broth. According to the nutrition facts on the chicken broth box, each packet of chicken broth provided 1100 milligrams (mg, a unit of measure) of sodium; when divided by four, this indicated that pureed pork provided of 275 mg of sodium; 223 mg excess sodium in comparison to the puree pork recipe. During an interview on 5/22/25 at 9:10 am, the Registered Dietician (RD) confirmed that food portions should be weighed using a scale, and that regular broth should not be used in the puree pork recipe. 2. A review of a facility's Food and Nutrition Services policy titled, Standardized Diets, rev. 01/2025, indicated that regular and therapeutic diets are planned to guide patient menu processing, meal production, preparation, tray assembly and delivery, and that serving sizes as outlined in the spreadsheet are to be followed. A review of a diet menu spreadsheet for the lunch meal for 5/21/25, indicated the following portion sizes; a #8 scoop (1/2 cup) for soft/bite size pork, a #8 scoop for puree sweet potatoes, and a #16 a scoop (1/4 cup) for pureed seasoned beets. During a concurrent observation and interview, for lunch tray line preparation on 5/21/25 at 10:22 am, [NAME] D was observed to use a #10 scoop (3/8 cup) to portion soft/bite size pork, and stated he did not have enough of the correct sized scoops. [NAME] D used a #12 scoop (1/3 cup) to portion puree sweet potatoes, and a #8 scoop to portion puree seasoned beets. During an interview on 5/22/25 at 9:10 am, the RD confirmed that the scoop sizes used should match the diet menu spreadsheets.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained when Certified Nursing Assistant (CNA) F did not perform hand hygiene between resident care. This had the potential to spread infection. Findings: A review of the facility's policy and procedure (P&P) titled, Infection Control, revised 7/1/20, indicated, facility staff would use alcohol-based hand gel upon entering and exiting a resident's room, touching a resident, and, After contact with inanimate objects (bed, curtains, bed rails, etc.) in the immediate vicinity of the patient. During an observation on 5/20/25 at 12:13 pm, CNA F was observed placing a dirty lunch tray into a metal cart. CNA F pulled a pen and paper out of the right leg pocket of her pants, wrote something down, and placed the pen and paper back into the pocket. CNA F walked into room [ROOM NUMBER] and removed a dirty lunch tray and placed it in the metal cart. CNA F pulled a pen and paper out of the right leg pocket of her pants, wrote something down, and placed the pen and paper back into the pocket. At 12:16 pm, CNA F walked into room [ROOM NUMBER] and touched the footboard of the bed, touched the privacy curtain that was between bed A and B, and exited the room. CNA F was observed walking into room [ROOM NUMBER], touched an item on the bedside table, picked up the dirty lunch tray, and placed it in the metal cart. CNA F opened the door to the nourishment refrigerator (contained drinks and snack food items for residents), moved something out of the way, removed a drink, and took it to the resident in room [ROOM NUMBER]. CNA F went back to the room where the nourishment refrigerator was located, and began opening cupboard doors, looking for crackers. The observation ended at 12:25 pm. During an interview on 5/20/25 at 12:26 pm, CNA F confirmed the entirety of the observation and stated, I didn't perform hand hygiene entering and exiting [resident] rooms, after placing dirty trays into cart, and in between each tray pick up. During an interview on 5/21/25 at 9:49 am, Director of Staff Development stated, hand hygiene was expected to be performed in between resident care, gel in, gel out, in between things that you're touching, and after touching dirty meal trays.

Based on interview and record review, the facility failed to ensure that a thorough investigation of an allegation of staff to resident abuse was conducted in accordance with the facility's Abuse Policy, for one of three sampled residents (Resident 1). This had the potential to put all residents of the facility at risk for staff to resident abuse. Findings: Review of a facility's policy titled, Abuse Prevention and Management: TCU dated 6/24 indicated, .each resident shall be free from verbal, sexual, physical and mental abuse . , Residents must not be subjected to abuse by anyone, including .staff of other agencies serving the resident , and The Administrator will: 4) Begin the interviewing process of all involved residents, employees and witnesses , and 7) Start a confidential file including: 1) Resident Statement, 2) Employee Statements 3) Witness Statements . Review of admission records for Resident 1, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including high blood pressure with heart failure (heart is unable to pump blood to meet the body's need), chronic kidney disease (the kidneys are damaged and can't filter blood the way they should), atrial fibrillation (an irregular and often very fast heart beat that can cause poor blood flow), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and overactive bladder (a problem with bladder function that causes the sudden uncontrollable urge to urinate). Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 13 out of 15, which indicated she was cognitively intact. Review of a Registered Nurse Note dated 1/27/25 at 10:18 AM, indicated that Resident 1 reported the alleged abuse to the Director of Staff Development (DSD), and stated to the DSD that around 1000 (10:00 PM) last night my CNA [Certified Nursing Assistant] got me back into bed after using the bathroom and hit me with my call light. The DSD indicated that Resident 1 showed him a bruise to her left hand. The DSD indicated that, although Resident 1 did not know the name of her CNA, that CNA E had been determined to be Resident 1's CNA. During an interview on 2/5/25 at 11:09 AM, with the DSD, the DSD stated Resident 1 pointed out a visible bruise on her left hand and indicated that CNA E hit her on the hand with the call light. The DSD stated that Resident 1 reported that she felt CNA E hit her on purpose. The DSD indicated that he could not recall who had been interviewed regarding this allegation, and confirmed there was no supporting documentation. The DSD was not able to describe CNA E, as he had never seen her. Review of a Case Manager note dated 1/29/25 at 2:00 PM, reflected Resident 1 didn't remember the allegation that CNA E had hit her with the call light and wasn't sure what the Case Manager was talking about. During a phone interview on 2/5/25 at 1:11 PM, with Resident 1, Resident 1 stated that on 1/26/25 around 10 PM, she was in bed and CNA E came in and was being a smart [NAME] with her and conked her on the hand with the call light and left a bruise. Resident 1 stated that she could not remember CNA E's name. Resident 1 stated that she slept the rest of the night and confirmed that she had not reported this to anyone until the next morning, on 1/27/25, she told, the big boss. During a phone interview on 2/5/25 at 1:54 PM, CNA E stated that around 3:00 AM on 1/27/25, she went into Resident 1's room and found that her call light was wedged in between her mattress and the bed rail. CNA E indicated that she untangled the call light and placed it within Resident 1's reach. CNA E stated, There was no indication that the call light had hit her [Resident 1] hand. She [Resident 1] never said anything. CNA E added if the call light had hit Resident 1's hand on accident, I would have reported it. During an interview and conncurrent Abuse Policy record review on 2/5/25 at 12:59 PM, the Director of Nursing (DON) and Chief Nursing Officer (CNO), confirmed the facility's investigation had not included the interviewing process of all involved other residents who had been under the care of CNA E, employees and witnesses, and there was no confidential file that included a resident statement, employee statements, or witness statements, as their Abuse policy directed. CNO stated Resident 1 should have been shown a picture of CNA E, to positively confirm that she was the person alleged to have hit her.

Based on interview and record review, the facility failed to carry out a resident's wishes for end of life treatment when the facility staff performed cardiopulmonary resuscitation (CPR, an emergency life-saving procedure when breathing or heart beat has stopped ), on one of three sampled residents (Resident 1) that chose not to have CPR not be performed. This resulted in Resident 1 receiving CPR and violated her end of life wishes. Findings: A review of the facility's policy titled, CODE BLUE [means someone is experiencing a life threatening medical emergency where their heart stopped or they are not breathing and staff are to respond immediately] reviewed ,d+[DATE], indicated, Section C: A 'CODE BLUE' will be called on all patients who experience a cardiac and/or respiratory arrest unless a DNR [Do not resuscitate means the same as No CPR] order is written on the patient's chart. Resident 1 was admitted to facility on [DATE] with a diagnosis of high blood pressure and congestive heart failure (CHF, when the heart is unable to pump enough blood to the body and fluid builds up in the lungs). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a document signed by a resident or their responsible party which specifies their end of life wishes), dated [DATE], indicated that Resident 1 desired No CPR. A review of Resident 1's Physician's Orders dated [DATE], indicated the physician had discussed CPR with Resident 1 and her family member and an order was written for DNR. A review of Resident 1's Progress Notes dated [DATE] at approximately 8:18 PM, indicated Resident 1 was found, unresponsive . without a detected pulse. A Code Blue (means someone is experiencing a life threatening medical emergency and the heart stops or they are not breathing and staff need to respond immediately) was called. Facility staff responded and began doing CPR on Resident 1. On [DATE] at 8:30 AM, an interview was conducted with the Chief Nursiing Officer (CNO). The CNO confirmed that Resident 1 had documented wishes for No CPR on her POLST and on her Physician's Orders, and should not have received CPR. The CNO added that there had been confusion with the verbiage on the POLST form and the facility has since revised the POLST form and implemented a new process. On [DATE] at 8:00 AM, Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, I was in getting meds for another patient and I heard the code called. I had to finish there and then I was able to go to the patient's [Resident 1] room. I was thinking that it is a DNR patient and I went in and confirmed that. I let everyone know [Resident 1] was a DNR patient. The doctor was there about the same time as me and was on the phone talking to [Resident 1's] family and the family member told us to continue CPR. The doctor told us to continue. I came in after it was started. I told everyone she was a DNR but CPR was already being performed. There was some confusion apparently about what type or level it was. On [DATE] at 8:40 AM the Medical Doctor (MD)1 was interviewed. MD 1 stated, I was in house [in the hospital] and responded to the code. I was told there was a POLST form and was told [Resident 1] was a DNR and I called [a family member]. That [family member] didn't answer so I called [another family member], who said since we were already coding [giving CPR] to continue and transport [Resident 1] to the hospital.

Based on observation, interview, and record review, the facility failed to maintain essential foodservice equipment in safe operating condition when: 1. The dish machine water temperature did not meet the manufacturer specified guidelines. 2. One hand washing sink in the food service area did not have hot water. 3. One of three ice machine storage bins was not cleaned per manufacturer specification. These failures had the potential to increase the risk of food and ice contamination, and subject the residents who ate food or used ice from the facility's kichen, to food borne illnesses such as stomach cramps, nausea, vomiting and diarrhea. Findings: 1. The National Sanitation Foundation (NSF) guidelines (instructions) posted on the facility dishwashing machine indicated that the minimum wash water temperature must be 130 degrees Fahrenheit (F, a unit of measuring temperatures), and the minimum rinse water temperature must be a minimum of 130 degrees F. Review of a facility policy titled, Physical Plant and Equipment Department Security reviewed 1/1/23 and in effect, indicated that equipment is operated according to manufacture instructions. Review of a facility policy titled, Dishwashing and Pot washing reviewed 1/1/23 and in effect, indicated that the water temperature needed to be 120 degrees F or higher, to clean and sanitize dishes using a chemical sanitization process (a process of using chemical cleaning solutions instead of very hot, over 160 degrees F, water temperatures). During a kitchen tour and concurrent interview with Facility Cook (FC) 1)on 3/4/24 at 10:29 AM, it was observed that the wash water temperature only reached 102 degrees F, and the rinse water temperature only reached 115 degrees F. FC1 indicated that the water temperature only needed to reach 120 degrees F, and stated, sometimes it needs to run a few cycles to get to 120 degrees. FC1 confirmed that the dishes he had just processed only reached 118 degrees F, and stated, it could be an issue with the fuse. FC1 ran the dishwashing machine through four cycles and the water temperature was observed reaching a maximum temperature of 120 degrees F. During a kitchen tour and concurrent interview on 3/4/24 at 10:43 AM, Registered Dietitian (RD) 1 confirmed that the facility uses a chemical sanitization dishwashing process and indicated water temperature was monitored and recorded in a logbook each shift. It was observed that the facility logbook contained printed guidance indicating that the dish machine minimum wash water temperature must be between 120 and 140 degrees F, and the rinse cycle should reach 130 degrees F. It was observed that on three out of three days with water temperature measurements recorded for the month of March 2024, indicated that the wash and rinse temperature only reached 125 degrees F when checked. It was observed during the kitchen tour that the actual wash and rinse temperature did not reach 120 degrees F during several wash and rinse cycles while FC1 was processing soiled dishes. RD1 confirmed by observation, that the dishwashing machine water was not reaching 120 degrees F, and that the manufacturer specified wash and rinse water temperature of 130 degrees F was different than the facility's logbook which specified wash and rinse water temperatures, and indicated she was not sure why the water temperatures were different. FC1 indicated that she would place a maintenance request and inform the Certified Dietary Manager (CDM). A record review of the facility's, Dish Machine Temperature logbook from 10/1/23 through 2/29/24, indicated that on 139 out of 152 days, water temperatures below the manufacturer's specified temperature of 130 degrees F were recorded by kitchen staff. During an interview on 3/5/24 at 8:47 AM, the CDM indicated that the dishwashing machine is a low temperature machine, and it uses chemicals to clean and sanitize the dishware. The CDM confirmed that the logbook used to record the dishwashing machine water temperatures indicated that a range of 120 to 140 is acceptable, and indicated he was aware that the manufacturer specifications for this dishwashing machine required a water temperature no less than 130 F. 2. According to USDA Food Code 2022, Section 5-202.12 Handwashing Sink, Installation (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 85 degrees F. Review of a facility policy titled, Physical Plant and Equipment Department Security reviewed 1/1/23 and in effect, indicated that handwashing stations would have hot water. During a tour of the facility kitchen on 3/4/24 at 9:30 AM, it was observed that one of three handwashing sinks (the sink near the resident meal tray line preparation area), did not have functioning hot water. During an interview on 3/4/24 at 9:50 AM, RD1 confirmed that the handwashing sink near the tray line preparation area did not have functioning hot water and confirmed that staff had not reported the nonfunctioning hot water. 3. Review of a facility policy titled, Physical Plant and Equipment Department Security reviewed 1/1/23 and in effect, indicated that equipment is operated according to manufacture instructions. Review of [NAME] ice machine manufacturer instructions provided by the facility on 3/5/24 at 2:15 PM, indicated that cleaning and sanitizing the ice machine required the use of Safe Clean (a chemical cleaning solution) for cleaning, and Calgon IMII (a chemical sanitizing solution) for sanitizing the ice storage bin. During an interview on 3/5/24 at 2:15 PM, the CDM indicated that the ice machine ice storage bin in the kitchen was cleaned monthly. CDM explained the process to turn off the machine, empty out the ice, remove the diverter plate, mix the sanitizing solution with water, clean the inside of the bin with the sanitizing solution (Calgon IMSII), rinse the bin and allow to air dry. CDM indicated that he used the dishwashing machine to clean the diverter plate, air dried the diverter plate and then reassembled the machine before turning it back on. CDM confirmed that he was only using the sanitizing solution (Calgon IMSII) and that he did not use the manufacture specified cleaning solution (SafeCLEAN) when cleaning the ice storage bin monthly and was not aware that the cleaning solution was needed.

Based on observation, interview, and record review, the facility failed to ensure that Food and Nutritional Services staff followed food safety and sanitation guidelines when: 1. Meat was not thawed properly. 2. Hand hygiene was not consistently performed. 3. The dish machine water temperature did not meet the manufacturer specified guidelines. 4. One hand washing sink in the food service area, did not have hot water. 5. Two of three ice machines were not clean. 6. The sanitizing storage process used for wiping cloths was not followed. 7. Hair restraints were not consistently used by kitchen and maintenance staff. 8. Food preparation equipment was not in good working order. 9. Food was stored in a used non-approved storage container. 10. Clean dishware was stored in soiled containers. 11. Two knife holders were not clean. These failures had the potential to increase the risk of food contamination and food borne illnesses, and subject the residents who ate food from the kitchen, to stomach cramps, nausea, vomiting and diarrhea. Findings: 1. Review of a facility policy titled, Employee Sanitation Practices, last reviewed on 1/1/2023 and in effect, indicated that meat would be thawed in the refrigerator below 40 degrees Fahrenheit (F a unit of measuring temperatures). And any meat thawed under running water would be fully submerged and completely thawed in less than two hours. Additionally, the policy indicated that meats thawed under running water would be fully prepared and cooked within four hours of removal from the freezer. During an interview and concurrent kitchen tour with Registered Dietitian (RD) 1 on 3/4/24 at 9:57 AM, it was observed that there was meat thawing in a sink under running water. RD1 confirmed that there was a pork shoulder (approximately 30-40 pounds), thawing under running water and indicated the meat had been removed from the freezer at approximately 8:57 AM. RD1 indicated that the pork will not be cooked for two days, which will be on Wednesday 3/6/24. During an interview with a Facility Cook (FC) 3 on 3/4/2024 at 10:39 AM, it was observed that there was chicken thawing in a sink. FC3 confirmed that the meat was chicken, and it was going to be cooked the next day, Tuesday 3/5/24. FC3 indicated it was alright to thaw the chicken under running water and stated, there is no log used to record when the meat was removed from the freezer or how long it was left under running water. FC3 indicated that the meat would be left under the running water until it was completely thawed, and then it would be stored in the refrigerator until it was cooked. FC3 stated, I do not know how long it will take to thaw the meat, and indicated the meat was checked on every 30 to 45 minutes, until thawed. During a kitchen tour on 3/4/2024 at 2:38 PM, it was observed that the chicken thawing since 10:39AM, was still thawing under running water in the sink. FC3 confirmed the chicken was placed in the sink around 10:30 AM (about 4 hours prior), and that it was going to be stored in the refrigerator until the next day when it was going to be cooked and served. During an interview on 3/4/24 at 2:40 PM, RD1 confirmed that meat can only thaw under running water for a maximum of two hours and all meats thawed under running water should be prepared within 4 hours of removal from the freezer. RD1 indicated that meat thawed under running water can not be stored in the refrigerator for future use and indicated the pork and chicken observed thawing under running water would be disposed of. During an interview on 3/5/24 at 8:40 AM, the Certified Dietary Manager (CDM), confirmed that the facility preference is for meat to be thawed in the refrigerator and indicated that chicken should not be thawed in the sink under running water. And stated, we only thaw meat under running water when we need to thaw it fast, and indicated was only done occasionally when staff was not available to remove the meat from the freezer. The CDM confirmed that meat thawed under running water needed to be prepared within four hours of removing it from the freezer, and that the thawing process must be completed within 2 hours. The CDM confirmed that the pork and chicken previously observed thawing under running water on 3/4/24, should have been under the running water for no more than 2 hours. The CDM indicated that the meat needed to be cooked within four hours and should not have been placed back into the refrigerator after the thawing process. The CDM indicated that the chicken and pork that was thawed in the sink on 3/4/24, was discarded due to the unsafe handling of the meat. 2. Review of a facility policy titled, Employee Sanitation Practices last reviewed on 1/1/2023 and in effect, indicated staff would wash hands with soap and hot water for a minimum of 20 seconds after handling soiled equipment, before handling any clean equipment and utensils (silverware), and before putting on gloves. Review of a facility policy titled, Dishwashing and Pot washing last reviewed 1/1/23 and in effect, indicated all staff must perform hand hygiene before handling any clean dishware. During a kitchen tour on 3/4/24 between 10:21 AM and 10:41 AM, FC1, was observed handling dirty dishes, removing soiled gloves, and then putting on clean gloves without performing hand hygiene, prior to handling clean dishware three at separate times, 10:21 AM, 10:29 AM and at 10:41AM. During an interview on 3/4/24 at 10:41 AM, RD1 confirmed that FC1 should have performed hand hygiene after removing soiled gloves, before putting on clean gloves, and before handling clean dishware. During an interview on 3/4/24 at 10:42 AM, FC1 indicated that he did not know he should wash his hands after removing dirty gloves, before putting on clean gloves, or before handling clean dishware. During an interview on 3/5/24 at 11:22 AM, the CDM confirmed that staff should perform hand hygiene after touching dirty items or surfaces, removing dirty gloves, before putting on clean gloves, before touching any clean dishware, working with any food prep items, and before handling food. 3. The National Sanitation Foundation (NSF) guidelines (instructions) posted on the facility's dishwashing machine indicated that the minimum temperatures for both washing and rinsing dishes, must be at least 130 degrees F. Review of a facility policy titled, Physical Plant and Equipment Department Security last reviewed 1/1/23 and in effect, indicated that equipment is operated according to manufacturer's instructions. Review of a facility's policy titled, Dishwashing and Pot washing last reviewed 1/1/23 and in effect, indicated that the water temperature should be 120 degrees F or higher, to clean and sanitize dishes using a chemical (cleaning solutions), sanitization process. During a kitchen tour and concurrent interview with FC1 on 3/4/2024 at 10:29 AM, it was observed that the dishwasher water washing temperature reached 102 degrees F, and the rinse water temperature reached 115 degrees F. FC1 indicated that the water temperature only needed to reach 120 degrees F and stated, sometimes it needs to run a few cycles to get to 120 degrees. FC1 confirmed that the dishes he had just processed only reached 118 degrees F and stated, it could be an issue with the fuse. FC1 ran the dishwashing machine through four cycles and the water temperature was observed reaching a maximum temperature of 120 degrees F. During a kitchen tour observation, review of dishwashing temperature logs, and concurrent interview on 3/4/2024 at 10:43 AM, RD1 confirmed that the facility uses a chemical sanitization dishwashing process and indicated that the water temperature was monitored and recorded in a logbook each shift. A review of the logbook contained printed guidance indicating that the dish machine minimum wash water temperature must be between 120 and 140 degrees F, and that the rinse cycle should reach 130 degrees F. The log dated March 2024, reflected that there were three days where the dish machine's washing and rinsing water temperatures recorded, only reached 125 degrees F. It had been observed during the kitchen tour, that the actual wash and rinse temperatures did not reach 120 degrees F during several wash and rinse cycles when FC1 processed soiled dishes. RD1 confirmed by observation that the dishwashing machine water was not reaching 120 degrees F. RD1 confirmed that the manufacturer's instructions for the dishwashing maching specified that wash and rinse water temperatures should be 130 degrees F, whereas their logbook guidance indicated temperatures between 120 and 140 degrees F, were acceptable. RD1 indicated she was not sure why the water temperature directions were different. FC1 indicated that she would place a maintenance request and inform the facility's CDM. A record review of the facility's, Dish Machine Temperature logbook from October 1, 2023 through February 29, 2024, indicated that on 139 of 152 days, the water temperatures recorded by staff, fell below the manufacturer's specified temperature of 130 degrees F. During an interview on 3/5/24 at 8:47 AM the CDM indicated that the dishwashing machine is a low temperature machine, and it uses chemicals to clean and sanitize the dishware. The CDM confirmed that the logbook used to record the dishwashing machine water temperatures indicated that a range of 120 to 140 is acceptable, and indicated he was aware that the manufacturer specifications for this dishwashing machine required a water temperature no less than 130 F. 4. According to the United States Department of Agriculture (USDA) Food Code 2022, Section 5-202.12 Handwashing Sink, Installation (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 85 degrees F. Review of a facility policy titled. Physical Plant and Equipment Department Security last reviewed 1/1/23 and in effect, indicated that handwashing stations would have hot water. During a tour of the facility's kitchen on 3/4/24 at 9:30 AM, it was observed that one of three handwashing sinks (the sink near the resident meal tray line preparation area), did not have functioning hot water. During an interview on 3/4/24 at 9:50 AM, RD1 confirmed that the handwashing sink near the tray line preparation area did not have functioning hot water and confirmed that staff had not reported the nonfunctioning hot water. 5. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During an observation of the ice machine cleaning process with the Regional Director of Plant Operations (RPO), on 3/4/24 at 3:12 PM, it was observed that there was calcification build-up (minerals cause the surface to become rough which makes it easy for germs to stick to that surface), in contact with the ice in two of three facility ice machines, one in the dining room and one in the nourishment room. The plastic ice chute and drip tray on the ice machine in the nourishment room was observed to be worn and had white calcified mineral deposits built up on the surfaces. The RPO confirmed that the ice machines in the dining and nourishment rooms were not clean and had calcified deposits in contact with the ice. The RPO and indicated the plastic chute and drip tray needed to be replaced, I routinely clean the ice machines every six months. 6. According to the USDA Food Code 2022 Annex Section 3-304.14 Wiping Cloths, Use Limitation: Soiled wiping cloths, especially when moist, can become breeding grounds for pathogens that could be transferred to food. Any wiping cloths that are not dry (except those used once and then laundered) must be stored in a sanitizer solution of adequate concentration between uses. Wiping cloths soiled with organic material can overcome the effectiveness of, and neutralize, the sanitizer. The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit. During a facility kitchen tour on 3/5/24 at 10:44 AM, it was observed that the red sanitizing bucket in the food preparation sink had large amounts of food debris (organic material) in the sanitizing solution and the cloth in the sanitizing solution was visibly soiled and not completely submerged in the sanitizing solution. During an interview on 3/5/24 at 10:44 AM, FC4 confirmed that the sanitizing solution in the red bucket had food debris in it and that the sanitizing solution needed to be changed. During an interview on 3/5/24 at 10:50 AM, the RDM confirmed that the facility did not have a log to keep track of when the sanitizing solution was changed and indicated that it should be changed every two hours. 7. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints, effectiveness. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, and utensils. Review of a facility policy titled, Employee Sanitation Practices, reviewed 1/1/23 and in effect, indicated that hair would be kept clean and covered with a cap or hair net and beards and mustaches will be covered. During a kitchen tour and observation with RD1 on 3/4/24 at 10:45 AM, FC4 was observed preparing food without a hairnet and instead was wearing a ball cap which exposed his hair and the hair on his arms was not covered. RD1 confirmed that FC4 was not wearing a hair net and should be. During an ice machine maintenance demonstration in the kitchen on 3/4/24 at 2:57 PM, with RD1 it was observed that RPO had facial hair and did not have a facial hair covering on. RD1 confirmed that RPO should have worn a facial hair cover while in the kitchen and when maintaining the ice machine. During an interview on 3/5/24 at 10:56 AM, the CDM indicated that he was not aware kitchen staff needed to cover body hair on the arms and stated, long sleaves are not sanitary. 8. According to the USDA Food Code 2022 Section 4-201.11 Equipment and Utensils: Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food. During a facility kitchen tour on 3/4/24 at 9:43 AM, it was observed that three cooking pans had visible wear and chipping to the surface coating, two cutting boards had wear, grooves, and material that easily chipped away, and a can opener blade was worn and a had thick dried dark substance accumulated at the base of the blade. RD1 confirmed that the can opener blade was not clean and should be replaced, that the pans were worn and should be replaced, and indicated that cutting boards with deep grooves or loose material that can easily dislodge needed to be replaced. 9. The USDA Food Code 2022 defines single use articles such as plastic tubs or buckets which do not meet the materials, durability, strength, and cleanability as specified under sections 4-101.11, 4-202.11 for multi-use utensils. During a facility kitchen tour on 3/5/24 at 10:55 AM, a plastic container labeled, baking powder was observed. The CDM indicated that the plastic container now labeled baking powder, was originally a mashed potato container and that thought it was alright to reuse the mashed potato container to store other dry foods. 10. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. Review of a facility policy titled, Dishwashing and Pot washing reviewed 1/1/23 and in effect, indicated that food storage equipment must be washed and sanitized before clean dishes are stored. During a kitchen tour on 3/5/24 at 10:50 AM, it was observed that there were four bins containing dishware on the clean side of the dish room. Debris and fluid were in the bottom of four out of four bins. The CDM confirmed that the four bins contained clean dishes, that there was debris and fluid accumulated in all four bins, and confirmed that the clean dishware had not been stored properly. 11. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch and the objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. During a facility kitchen tour on 3/4/24 at 10 AM, it was observed that debris had accumulated on top of two of two knife holders in the food preparation area. RD1 confirmed that there was debris on top of two of two knife holders in the food preparation area and that the two knife holders should be cleaned.

Based on observation, interview, and record review, the facility failed to ensure that their facility cooks (FC), were trained to safely prepare food and adhere to sanitation requirements in the kitchen when: 1. FC3 did not thaw chicken in accordance with their food safety policy; and 2. FC1 did not perform hand hygiene after removing gloves; and 3.FC1 did not have knowledge of how to properly conduct manual dishwashing procedures, (when dishes are washed in a sink by hand, instead of in a dishwasher). These failures had the potential to increase the risk of food contamination with bacteria and subject the residents to food borne illness such as stomach cramps, nausea, vomiting and diarrhea. Findings: 1. Review of a facility provided record titled, Performance & Goal Review Form dated 2/28/24, indicated that the facility's Certified Dietary Manager (CDM), determined FC3 was compliant with all facility policies. Review of a facility provided record titled, Job Description and Competencies indicated facility cooks would complete a California approved food handling course, maintain high standards of food quality, prevent cross contamination, and be knowledgeable in sanitation practices. Review of a facility policy titled, Employee Sanitation Practices last reviewed on 1/1/2023, and in effect, indicated that fish and poultry would be thawed in the refrigerator below 40 degrees Fahrenheit (F). And any meat thawed under running water would be fully submerged and completely thawed in less than two hours. Additionally, the policy indicated that meats thawed under running water would be fully prepared and cooked within four hours of removal from the freezer. During an interview with FC3 on 3/4/2024 at 10:39 AM, it was observed that there were two plastic tubs of completely frozen chicken (approximately 20 -30 pounds) thawing in a sink. FC3 confirmed that it was chicken, and it was going to be cooked the next day, Tuesday 3/5/24. FC3 indicated it was alright to thaw chicken under running water and stated, there is no log used to record when the meat was removed from the freezer or how long it was left under running water. FC3 indicated that the meat would be left under the running water until it was completely thawed, and then it would be stored in the refrigerator until it was cooked. FC3 stated, I do not know how long it will take to thaw the meat, and indicated she checked on the chicken every 30 to 45 minutes until thawed. During a kitchen tour on 3/4/2024 at 2:38 PM, it was observed that the chicken thawing at 10:39AM, was still thawing under running water in the sink. FC3 confirmed the chicken was placed in the sink around 10:30 AM (about 4 hours prior), and that it was going to be stored in the refrigerator, until the next day, when it was going to be cooked and served. During an interview on 3/4/24 at 2:40 PM, Registered Dietitian (RD) 1 confirmed that meat can only thaw under running water for a maximum of two hours and all meats thawed under running water should be prepared within four hours of removal from the freezer. RD1 indicated that meat thawed under running water cannot be stored in the refrigerator for future use and indicated the chicken observed thawing under running water would be disposed of. During an interview on 3/5/24 at 8:40 AM, the Certified Dietary Manager (CDM) confirmed that the facility preference is for meat to be thawed in the refrigerator and indicated that chicken should not be thawed in the sink under running water. And stated, we only thaw meat under running water when we need to thaw it fast, and indicated was only done occasionally when staff was not available to remove the meat from the freezer. The CDM confirmed that meat thawed under running water needed to be prepared within four hours of removing it from the freezer, and that the thawing process must be completed within two hours. The CDM confirmed that the chicken should not be thawed under running water and indicated it should only be thawed in the refrigerator. The CDM indicated that the chicken thawed in the sink on 3/4/24 was discarded due to unsafe handling. 2. Review of a facility provided record titled, Job Description and Competencies indicated facility cooks would apply handwashing principles, complete a California approved food handling course, maintain high standards of food quality, prevent cross contamination, and be knowledgeable in sanitation practices. Review of a facility policy titled, Employee Sanitation Practices last reviewed on 1/1/2023, and in effect, indicated staff would wash hands with soap and hot water for a minimum of 20 seconds after handling soiled equipment, before handling any clean equipment and utensils (silverware), and before donning gloves. Review of a facility policy titled, Dishwashing and Pot washing last reviewed 1/1/23 and in effect, indicated all staff must perform hand hygiene before handling any clean dishware. Review of a facility provided document titled, Core Competency Demonstration Cook indicated that FC1 was competent at performing hand hygiene and followed approved procedures. During a kitchen tour on 3/4/24 between 10:21 AM and 10:41 AM, FC1 was observed handling dirty dishes, removing soiled gloves, and then donning clean gloves without performing hand hygiene prior to handling clean dishware three separate times, at 10:21 AM, 10:29 AM and 10:41AM. During an interview on 3/4/24 at 10:41 AM, RD1 confirmed that FC1 should perform hand hygiene after removing soiled gloves, before donning clean gloves, and before handling clean dishware. During an interview on 3/4/24 at 10:42 AM, FC1 indicated he did not know he should wash his hands after removing dirty gloves, before donning clean gloves, and before handling clean dishes and silverware. During an interview on 3/5/24 at 11:22 AM, the CDM confirmed that staff should perform hand hygiene after touching dirty items or surfaces, removing dirty gloves, before donning clean gloves, before touching any clean dishes or silverware, working with any food prep items, and before handling food. 3. According to USDA Food Code 2022, Section 4-501.19 Manual Ware washing Equipment, Wash Solution Temperature. The temperature of the wash solution in manual shall WARE WASHING EQUIPMENT, be maintained at not less than 43 degrees Celcius (C, a unit of measuring temperature), or 110 degrees Fahrenheit (F, a unit of measuring temperature), or the temperature specified on the cleaning agent manufacturer's label instructions. Review of facility provided records titled, Job Description and Competencies indicated facility cooks would compete a California approved food handling course, would maintain high standards of food quality, prevent cross contamination, and be knowledgeable in sanitation practices. Review of a facility provided document titled, Core Competency Demonstration, Cook indicated that FC1 was competent at cleaning and sanitizing dishware, utensils, and work areas. And indicated that FC1 was competent in the dish room and able to effectively clean and sanitize all dishware used for tray line (where food is placed on trays for the residents). Review of a facility provided document titled, Dietary In-Service Notes, on 8/9/23 indicated that the facility CDM provided education on manual dishware washing to FC1. And the printed handout included with the education indicated that the dishware washing solution only needed to be 100 degrees F or the temperature on the cleaning agent manufactures label. And that the dishware should soak in the sanitizing solution for at least 30 seconds. Review of an undated facility posting in the manual ware washing room titled, Three Compartment Sink Procedures indicated that the wash water temperature needed to be a minimum of 110 degrees F, and that the dishware must be completely submerged in the sanitizing solution for a minimum of one minute. During a kitchen tour and concurrent interview on 3/5/24 at 2:02 PM, FC1 indicated he did not know what the water temperature should be when manually washing dishware and was referred to the poster on the wall that indicated the wash water needed to be maintained at a minimum of 110 degrees F. FC1 stated, the dishware should soak in the sanitizer for about 30 seconds. FC1 demonstrated the process used to test the dishware sanitizing solution. It was observed that FC1 submerged the test strip into the dishware sanitizing solution, then removed it immediately, and did not follow the test strip manufactures instructions (printed on the package). FC1 was referred to the test strip package that indicated that test strip should be submerged in the sanitizing solution for five seconds, removed form the solution and then analyzed. FC1 was observed resubmerging the same test strip into the sanitizing solution for more than five seconds, and then indicated the sanitizing solution was the appropriate concentration.

Based on interview and record review, this requirement was not met when a Certified Nursing Assistant (CNA 1) yelled, Don't yell at me to one of 16 sampled residents (Resident 6), and was loud enough that Resident 75, Resident 20, and visiting family members (FAM 1) overheard it. This had the potential to compromise Resident 6's dignity and negatively impact other resident's emotional and psychosocial well-being and create an environment of fear. Findings: Resident 6's Admission Record was reviewed and indicated that Resident 6 was admitted to the facility for conditions including dementia (a disease that causes memory and thought processes to deteriorate). Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated January, 2023 indicated, It is the practice of [the facility] to protect and promote resident rights and treat each resident with respect and dignity . The policy further stated, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; and, 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. Review of the facility's document titled, Allegation of Abuse, dated 3/6/24, indicated that CNA 1 was witnessed yelling aggressively and loudly at a patient with dementia [Resident 6], witnessed by the charge nurse, Registered Nurse (RN) 2 and other visitors and had made the visitors, jump. The record further indicated that CNA 1 had violated hospital policies pertaining to Professional Code of Conduct and Promoting/Maintaining Resident Dignity. In an interview on 3/4/24 at 10:55 AM, Resident 75 stated that her FAM 1 overheard staff and a resident yelling across the hall. The man across the hall is very noisy all the time, always yelling at people. Resident 75 stated that she had heard staff yelling back. In an interview on 3/4/24 at 11:55 AM, Resident 20, whose room is next to Resident 6's, stated, The gentleman next door is very loud, yells every day at staff. CNAs yell back, it's very loud here. In an interview on 3/5/24 at 1:04 PM, CNA 1 stated that on 3/1/24, she was helping Resident 6 put on his foot braces. He had been yelling at me all day long, and when he yelled at me again, I used my 'mom voice' and yelled back at him. I apologized, I was frustrated. In an interview on 3/05/24 at 2:12 PM, Interim Director of Nursing (IDON) stated that she was the first supervisor to receive a call from Licensed Vocational Nurse (LVN) 1 who was charge nurse that afternoon. IDON stated that LVN 1 reported that she heard CNA 1 speaking loud and yelling at resident across the hall. They argued back and forth. IDON stated that in all such instances, the staff member had to be taken off of the nursing floor while the incident was investigated. In an interview on 3/5/24 at 1:37 PM, Resident 75's FAM 1 stated that on 3/1/24, she was visiting her mother, whose room is directly across the hall from Resident 6. FAM 1 stated that she overheard a CNA across the room raising her voice and yelling at a resident in a loud tone, and was then overheard swearing in the hall. In an interview on 3/6/24 at 9:05 AM, LVN 1 stated that she was with a resident's family across the hall and heard CNA 1 yelling at Resident 6, I don't care, don't yell at me! this was loud enough that two family members overheard it and were startled by it. LVN 1 further stated that she was alarmed by the tone of voice used by CNA 1 to Resident 6, and that she reported this because the manner in which CNA 1 spoke to Resident 6 violated the facility's Code of Conduct.

Based on interview and record review, the facility failed to ensure that their, Food from Outside Sources policy (outside sources are food from any other source than the facility's kitchen), included procedures on how to heat or reheat resident food that had been brought in from the outside or contained education for staff and visitors on safe food handling practices and potentially hazardous foods, (PHF-food that allows for rapid progression and growth of bacteria; such as food that consists in whole or part of milk, milk products, eggs, meat, poultry, rice, fish shellfish, edible crustaceans, raw-seed sprouts, and vegetables including heat-treated vegetables). This failure had the potential for residents who received food from a source to be subjected to contaminated food and food borne illnesses such as stomach cramps, nausea, vomiting, diarrhea and food poisoning. Findings: Review of the facility's policy titled, Food from Outside Sources reviewed 1/22, indicated patients are encouraged to consume facility meals, snacks and supplements to assure adequate nutrition and reduce the risk of contamination. To support patient's nutrient intake, foods from outside sources may be provided to patients with appropriate storage and handling. Procedure: 3. Potentially hazardous foods may not be stored in patient rooms and should be eaten upon receipt. Review of the facility's document titled, Outside Food Storage undated, indicated, Staff cannot reheat your food for you. Review of the facility's document titled, Patient Foods Brought From Outside Facility written by the facility's Certified Dietary Manager, indicated hot items brought into the facility for residents, should be consumed within one hour to ensure food safety and cannot be kept and reheated. On 3/4/24 at 11:54 AM, an interview was conducted with Licensed Vocational Nurse (LVN) 1 regarding food brought to the facility from outside sources. When asked if LVN 1 had received education on safe food handling, LVN 1 stated, For the most part, yes. When asked how visitors were educated on safe food handling, LVN 1 stated the facility provided visitors with a copy of the policy on food from outside sources upon admission. On 3/5/24 at 9:30 AM, an interview was conducted with LVN 1. LVN 1 stated the facility did not heat or reheat food from outside sources because they could not regulate the temperature of the food. On 3/5/24 at 2:21 PM, an interview was conducted with the Director of Staff Development (DSD). When asked if facility staff had been educated on safe food handling, the DSD indicated that she went over the policy on food from outside sources and that the education on safe food handling was the Registered Dietitian's (RD) responsibility. On 3/5/24 at 2:43 PM, an interview was conducted with the RD. When asked how visitors were educated on safe food handling, the RD stated visitors were provided a copy of the facility's policy on food brought from outside sources. The RD stated she tried to review safe food handling with visitors verbally, but visitors were not provided anything in writing regarding safe food handling. The RD added the facility did not reheat food brought from outside sources because the facility staff had not been trained to check food temperatures.

Based on interview and record review, the facility failed to ensure federal regulations related to the education qualification requirements of the Certified Dietary Manager (CDM), were followed as outlined in the California Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines. Findings: According to the HSC 1265.4 a CDM, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. On 3/5/24 at 8:34 AM, an interview was conducted with the CDM. The CDM stated that he completed the CDM course through an online university from North Dakota. The CDM stated he was not aware of the requirement of six hours of training on specific California dietary service requirements contained in Title 22 of the California Code of Regulations as specified in the HSC 1265.4, and that he had not met this requirement. On 3/6/24 at 8:25 AM, an interview was conducted with the Facility Administrator (FA). The FA stated she was not aware of the requirement of six hours of training on specific California dietary service requirements contained in Title 22 of the California Code of Regulations as specified in the HSC 1265.4.

Based on interview and record review the facility failed to employ a full time, 40 hour a week, dedicated, Director of Nursing (DON) who was responsible for the oversight of the delivery of nursing care services for residents. This had the potential to affect the quality of care and life of all residents in the facility. Findings: A review of a facility policy titled Job description and Competencies Director of Nursing revised November 2018, indicated; the Director of Nursing was responsible for the administration of nursing services in the Skilled Nursing Facility/Transitional Care Unit. Directs, plans, and coordinates service activities of professional nursing and auxiliary nursing personnel in rendering customer care. Interprets facility policies and regulations to all nursing personnel and ensures compliance, as well as analyzes and evaluates nursing and related services rendered to improve quality of customer care and to better utilize staff time and abilities. Also ensures the provision of in-service training programs for nursing personnel. Ability to identify and implement components of the nursing process. Identify learning needs and teach patients and families. Ability to communicate and collaborate with a variety of teams and individuals. Working knowledge and ability to apply professional standards of practice in job situations. Coordinates and monitors all patient care services. Responsible for all activities relevant to patient care services. Assures compliance with all local, state, and federal laws regarding licensure and certification of staff. During an interview on 3/3/23 at 12:15 PM, the Chief Clinical Officer (CCO) for the Long-Term Acute Care (LTAC) hospital which had a 50-bed capacity. CCO explained that she was also working as interim Director of Nursing (DON) for the Skilled Nursing Facility (SNF) which had a 32-bed capacity. CCO stated she was unable to dedicate 40 hours a week to her DON role at the SNF due to her role as CCO in the LTAC. CCO stated the DON job position was posted and the last applicant interviewed was in October 2022. CCO stated the SNF did not have a dedicated fulltime (40 hours a week) DON for at least a year.

Based on observation, interview, and record review the facility failed to ensure that staff treated one of two sampled residents (Resident 1) with respect and dignity while providing care and responding to concerns. This resulted in increased emotional distress including hopelessness, anxiety, tearfulness, and depression for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE], with diagnosis which included an infection and inflammatory (immune system) response from an implanted post-surgical fixation device (surgical hardware). Review of a Minimum Data Sets (resident assessment tool) dated 9/11/22, 12/10/22, and 3/10/23 indicated that Resident 1 was consistently cognitively (normal thought process) intact and was able to make her own decisions. A review of and undated facility policy titled Promoting and Maintaining Resident Dignity indicated that staff would respond to a resident's request for assistance in a timely manner, speak respectfully, respect their living space/personal possessions and that the resident's former lifestyle/ personal choices are considered when providing care and services. During an interview on 3/3/23, at 10:00 AM, Resident 1 stated, the staff treats me different than my roommate, one of the Certified Nursing Assistants (CNA 1) is rude . Resident 1 explained CNA 1 was rude to her; first, when she requested a soda and then responded with an attitude after Resident 1 pushed her call light to request help for her roommate (Resident 2). Resident 1 explained that CNA 1 took a long time to get the soda and when she came in the room next, she had put her hands on her hips and stated, what do you need now, I was just in here . Resident 1 indicated that CNA 1 had been rude to her before and that she felt she was being singled out because CNA 1 treated her roommate (Resident 2) differently. Resident 1 explained, a Licensed Nurse (LN 1) was passing medications, had been cussing, and slamming the medication cart drawers in the hallway just outside her door. Resident 1 explained that she had asked LN 1 if everything was alright, and that the nurse seemed upset and rushed off to retrieve a medication. Resident 1 confirmed that LN 1 had not been in her room since. Resident 1 explained, the Chief Clinical Officer (CCO) and the Director of Quality and Risk Management (DQRM) came into her room to discuss a request to change her diet preferences when the CCO used a loud voice and was confrontational. Resident 1 stated, after requesting a change in diet, the interactions with staff felt confrontational. Resident 1 was observed tearful, and requested the door be closed. Resident 1 indicated that interactions with facility staff had affected her ability to participate in needed therapies and that she felt more tearful, depressed, and anxious than before. Resident 1 stated, Sometimes I feel like ending it all. Resident 1 indicated that she would not harm herself, had no plan to harm herself and felt safe but the interactions with staff had made her feel bad. During an interview on 3/3/23, at 10:40 AM, Resident 2 stated, the nurses are busy, and short staffed, but they are nice to me; I did notice staff treated me differently than my roommate (Resident 1), and they had a second person standing at the door like she was in trouble or something. Resident 2 indicated CNA 1 was rude to her roommate (Resident 1) several times, even when Resident 1 had pushed the call light because she needed help from staff and could not reach her own. Resident 2 explained she had witnessed the CCO and DQRM speaking loudly at Resident 1. Review of a Progress Note dated 2/17/22, DQRM documented that Resident 1 notified staff that she had a personality clash with CNA 1 who provided her care during the previous shift and reported LN 1 had loudly slammed the medication cart drawers and cursed just outside her room. Review of a Nursing Note dated 2/23/23 at 11:07 AM, DQRM documented that while at bedside with CCO discussing Resident 1's diet requests, the resident became upset and stated that she had felt like that CCO had been confrontational and used a loud voice. During an interview on 3/3/23 at 12:15 AM the CCO stated, this resident has had multiple complaints about many of the staff, even me. CCO stated, the resident told me she felt I was yelling at her and being confrontational . CCO confirmed that she used a loud voice when she was in Resident 1's room. CCO confirmed that the staff had been instructed to enter Resident 1's room two at a time and that Resident 1 expressed this caused her to feel more emotional. CCO explained the relationship with Resident 1 became too friendly and needed more professional boundaries. Review of a Facility document titled Job Description and Chief Clinical Officer (CCO), dated 5/1/17, indicated that the CCO would cultivate, advocate, demonstrates and understands the importance of respect for the rights, dignity, and individuality of each Resident in all interactions. Review of a Facility document titled Job Description and Competencies Director of Nursing (DON), dated 11/1/18, indicated that the DON would cultivate, advocate, demonstrates and understands the importance of respect for the rights, dignity, and individuality of each Resident in all interactions.

Based on observation, interview, and record review the facility failed to provide medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being for one of two Residents (Resident 1). This resulted in Resident 1 to experience increased emotional distress including hopelessness, anxiety, tearfulness, and depression. Findings: Resident 1 was admitted to the facility on [DATE], for infection and inflammatory (immune system) response from an implanted post-surgical fixation device (surgical hardware). Review of Minimum Data Set (MDS, resident assessment) dated 9/11/22, 12/10/22, and 3/10/23 indicated that Resident 1 was consistently cognitively intact (normal though process) and was able to make her own decisions. Review of the MDS Section D (mood assessment) dated 9/11/22, 12/10/22, and 3/10/22 indicated that Resident 1 was rarely or never understood, and because of this the depression screening interview was not completed with her. Licensed staff performed the depression screening interview and documented that she had no indicators of depression. A review of policy titled Abuse Prevention and Management , revised on 5/1/18, indicated residents would be free of abuse including incidents of verbal abuse, that the facility staff would investigate any allegations of abuse, will ensure the Social Worker evaluates the resident to determine if there are any psychosocial affects following the incident. A review of a policy titled Resident Rights , revised on 3/1/18, indicated that Social Services would continue to monitor adherence to resident's individual rights, as necessary, throughout the resident's stay, as well as promote their rights and assure they are upheld; and monitor and intervene with staff, residents and family members with complaints and grievances. He/she will [NAME] differences, problems, or issues as they arise or are referred to the department. Review of a Job Description and Competencies - Social Worker, dated 6/1/17, indicated that a Licensed Clinical Social Worker (LCSW) would provide patient assessment, counseling, and discharge planning and act as a liaison between the patient, family, and hospital. During an interview on 3/3/23, at 10 AM, Resident 1 stated, after requesting a change in diet, the interactions with staff felt confrontational . Resident 1 was observed tearful, and requested the door be closed. Resident 1 indicated that interactions with staff had affected her ability to participate in needed therapies and that she felt more tearful, depressed, and anxious than before. Resident 1 stated, Sometimes I feel like ending it all . Resident 1 indicated that she would not harm herself, had no plan to harm herself and felt safe but the interactions with staff had made her feel bad. Review of Care Plan Notes dated 1/31/23, a Student Social Worker (SSW 1) documented that Resident 1 had a depressed affect, expressed worry and concern related to her care and continued to struggle with anxiety. Review of Care Plan Notes dated between 12/13/22 and 2/3/23, indicated SSW 1, provided five counseling sessions to Resident 1 and the last documented session was on 2/23/23. Resident 1's depression and anxiety were discussed during four out of five counseling sessions; one session was declined by Resident 1. Resident 1 had a depressed affect during three of four remaining counseling sessions provided by SSW 1. Resident 1 continued to struggle with coping during for of the counseling sessions provided by SSW 1. During a concurrent interview and record review on 3/3/23 at 12 PM, the Director of Quality and Risk Management (DQRM) confirmed there were no notes in Resident 1's medical record by the Licensed Clinical Social Worker (LCSW 1). DQRM confirmed that there was no telehealth behavioral health (consult through internet) or psychiatric consults in Resident 1's medical record. Review of a progress note dated 3/7/23 at 5:09 PM, LCSW 1 documented that she consulted the SSW 1 over the duration of his treatments, provided assessment screening materials and reviewed the treatment plan in response to Resident 1's increased expressed feelings of being overwhelmed to staff. This was the first note entry since Resident 1's admission on 6/13/22. LCSW 1 did not document that she had assessed Resident 1 in person. Review of a progress note dated 3/16/23 at 5:39 PM, LCSW 1 documented a supervisory visit to Resident 1, that she denied having coping issues and was positive in spirits. This was the second LCSW 1 note entry since admission. During an interview on 3/24/23 at 9:20 AM, the Chief Clinical Officer (CCO) for the Long-Term Acute Care (LTAC) hospital which is 50 bed capacity stated she is interim Director of Nursing (DON) for the Skilled Nursing Facility (SNF) which had a 32-bed capacity. CCO stated the facility had one LCSW (LCSW 1), her schedule was Tuesday and Thursday and has student four days a week. CCO stated they both deal with psychosocial issues mainly in the skilled nursing facility. During an interview on 3/27/23 at 11:30 AM, SSW 1 explained he was a student studying marriage and family therapy. SSW 1 stated that he participated in an unpaid internship at the facility and provided counseling services to Resident 1. SSW 1 stated he worked under that supervision of the LCSW 1, who reviewed and cosigned all his notes but did not actively participate in his counseling sessions with Resident 1. SSW 1 confirmed that Resident 1 had expressed worry and concern related to her care and treatment by staff. SSW 1 stated, she has been in the facility a long time; she has the hospital blues. SSW 1 stated that Resident 1 had discussed the interactions with staff get her down sometimes. When asked how the facility had assessed Resident 1 for potential risk of self-harm SSW 1 stated, Resident 1 has not made any statements of self-harm; I personally completed the [NAME] Suicide Screening with Resident 1 within the last 2-3 weeks, Resident 1 was non-suicidal. During an interview on 3/28/23 at 9:00 AM, LCSW 1 stated that she had been working part time, typically 16 hours per week. LCSW 1 explained that she splits her hours between SNF and the LTAC. LCSW 1 stated most of her time was spent at the SNF (12-13 hours per week). LCSW 1 explained her other duties included monthly new staff orientation, precepting, and education presentations for staff. LCSW 1 stated she felt she was given adequate time to meet the needs of all the residents in the SNF and LTAC. LCSW 1 stated that typically the SNF residents are higher acuity and require more services. LCSW 1 stated, A student social worker, assists me with my case load; I oversee the student. LCSW 1 explained that she personally participated in all Resident 1's assessments, care plans, and treatment monitoring. LCSW 1 confirmed that she was not present when SSW 1 met with Resident 1 to provide counseling sessions. When asked to explain the process for cosigning notes written by students LCSW 1 explained Well-Sky (electronic medical record) was not equipped with a cosign feature. LCSW 1 stated, I read all of the students notes and documented that I agreed with his treatment plans in separate notes. LCSW 1 stated she had assessed Resident 1 in the last 2 weeks and gave her a writing assignment. LCSW 1 stated, I documented under Case Management Notes and my last note was 2-3 weeks ago.

Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The Registered Dietitian (RD) did not work full time in the Food and Nutrition Services kitchen, and the Dietary Manager (DM) did not meet qualifications for a director of food and nutrition services. 2. There was not an effective system in place to ensure effective staff training and competency in critical elements of food safety, and staff work practice deficiencies were not identified or corrected by the Registered Dietitian providing oversight to the kitchen, or by the Dietary Manager. These failures had the potential to result in foodborne illness and a decline in medical status for all residents living in the facility. Findings: Review of a policy titled, Organizational Structure/Relationships with Other Departments, revised 10/16, reviewed 1/22, indicated, The Registered Dietitian (RD) is responsible for oversight of Food & Nutrition Service. The Registered Dietitian is qualified by training, licensure and experience to manage the Nutrition Program of the hospital and provide oversight of daily operations of Food and Nutrition services and Department personnel. During an interview with the Administrator (ADMIN) on 2/17/23 at 9 am she was asked about the RDs role in the TCU (Transitional Care Unit). She stated she called the clinical side of the work the Nutritional Services Department, and she called the kitchen side of the work the Dietary Department. The ADMIN explained the RDs were responsible for nutrition care processes, but also assisted in the creation and approval of menus, worked with the menus and therapeutic diets, assisted the dietary staff and menu planners, and helped with menu substitutions. The RDs also did kitchen (food safety and sanitation) audits, and test trays regarding food appearance and temperature, and provided monthly reports to the QAPI (Quality Assurance/Performance Improvement) Committee. The Admin stated her expectations of the RD and DM roles were, the RDs oversaw therapeutic diets and menus, and the DM oversaw personnel issues. She stated RD oversight of the kitchen meant the food that goes out. The ADMIN stated the Dietary Department, was led by the DM who was responsible for budget, staffing, ordering food, etc. When asked about in-service education for kitchen staff, ADMIN noted Speech Therapy did an in-service about textures and menus. She stated the RDs will go anytime to address any issue. I know the RDs have done in-services for Dietary, maybe not in the past. When asked about the Dietary Manager role, ADMIN stated she expected them to oversee the dietary staff and provide some oversight with the menu planner. The DM did payroll, food ordering and receiving, budget, and assisted with training staff. When asked about the qualifications of the Dietary Manager the ADMIN stated the DM had ServSafe certification, years of experience, and had taken some classes. She did not know the regulatory requirements for the position. She stated she believed the kitchen was more of a collaborative effort between the RD and the DM. The RD does not have the final responsibility. The dietary staff do have food handler safety cards. 1. The Registered Dietitian (RD) did not work full time in the food services kitchen, and the Dietary Manager (DM) did not meet qualifications for a director of food and nutrition services. 1A. Registered Dietitian Review of a document provided by Human Resources titled Job Description and Competencies Clinical Dietitian revised 4/2018 described clinical nutrition responsibilities such as nutrition assessments, care plans and patient education, but it did not include any responsibility for the Registered Dietitian to provide oversight of the Food and Nutrition Services/kitchen. During an interview with the RD on 2/16/23 at 3:03 pm, he stated his role in the kitchen was fairly minimal and the DM took care of most of the kitchen. The RD explained his role in the kitchen included monthly meal tray evaluations (test trays) and monthly kitchen audits. He stated his kitchen audits involved looking for cleanliness, food storage practices, labeling and dating, temperature logs filled out correctly, and he also monitored food safety procedures during tray line (handwashing, glove use, scoop sizes). He stated when opportunities for improvement were found during his inspections staff corrected it immediately. The RD stated he had nothing to do with QAPI (Quality Assurance/Performance Improvement) in the kitchen. He only did clinical nutrition QAPI. The RD stated he did not provide in-service training for dietary staff but showed up when invited for RD-related issues. Review of facility RD's competency documents, provided by Human Resources, titled, Clinical Competency Review - Registered Dietitian Credentialing. The TCU RDs document was dated 6/10/22. While the verification of the RD's credential was provided, there was no evidence provided that showed the facility had provided orientation, training, or competency evaluation to the RD specific to oversight of the facility's food services. 1B. Dietary Manager: Review of a document provided by Human Resources titled, Job Description and Competencies Dietary Manager/Supervisor, revised 7/2018, described responsibilities including administrative support for food purchasing, preparation and distribution; proper sanitation, safety and infection control; supervision and training of Nutrition Services employees; and conformance with regulatory requirements and facility/department policies and procedures. The listed minimum qualifications included an associate degree or equivalent experience in related field required; minimum one year of previous managerial experience in a healthcare setting required; Therapeutic diet experience required; food handling certification as required by State regulations. During an interview with the DM on 2/16/23 at 2:20 pm, he stated he worked at the facility for seven years, first as a dish washer, then a cook, and had been the manager since October 2020. He stated he had been a chef/cook for almost 3 decades, had an associate of arts (AA) degree in culinary arts from Shasta College, and had a ServSafe Food Protection Manager Certification. The DM stated he was not a Dietary Services Supervisor or a Certified Dietary Manager, however the facility indicated he didn't need to have those certifications. The DM stated he didn't have much interaction with residents. He worked together with the RDs and they were all very good. Review of documents provided by Human Resources showed the qualifications of DM included a ServSafe Certification with expiration date 4/29/26, and a California Food Handler Certificate of Completion, valid through 12/18/23. They did not provide a copy of his AA degree in culinary arts or show his transcripts had been evaluated by a qualified program to support that the DM was qualified. 2. There was not an effective system in place to ensure staff training and competency, or monitoring of staff work behaviors, and the failures were not identified by the Registered Dietitian providing oversight to the kitchen, or the Dietary Manager (Cross Reference F802 and F812) During multiple observations, interviews, and record reviews in the kitchen with Food and Nutrition Services staff during the survey, food safety concerns were identified including: 2A. Food cooling not performed correctly or consistently for hot Time Temperature Control for Food Safety (TCS) foods, was not performed for cooked pasta found in the refrigerator, or for potentially ambient temperature foods such as egg salad, chicken salad or tuna. (Cross Reference F802, F812) When the DM was interviewed on 2/15/23 at 10:05 am regarding the process for food cooling, he did not describe the two-step food cooling process shown in the Employee Sanitation Practice policy that is also a professional standard of practice for food safety. During an interview with the RD on 2/16/23 at 3:03 pm, the RD was asked if he monitored food cooling. He stated he would have to double check to see if that was on the list. He couldn't remember off the top of his head. He stated he didn't know about the food cooling process. I was hired to be a clinical dietitian. Review of a policy titled, Employee Sanitation Practice, dated 4/19, described the two-step process for food safety. Review of five monthly cooling logs dated October 2022 through February 2023 showed seven out of seven entries were performed incorrectly. There was no evidence the logs were reviewed, or the problem identified by the RD or the DM. Review of three, monthly kitchen audits performed by the RD, titled, Sanitation and Food Safety Checklist, dated 12/15/21, 11/30/22, and 1/31/23, showed proper cooling methods of cooked foods are used and recorded on Cool Down Log per policy - yes. 2.B Vegetable wash not performed per manufacturer's instructions, gloves not changed between tasks, equipment not cleaned according to professional standards of practice. (Cross Reference F802, F812). In addition, recipes and menus were not followed, and residents complained regarding flavor and temperature of foods served, and availability of alternative food choices (Cross Reference F804, F806). During an observation and concurrent interview on 2/14/23 at 10:49 am, there was not a system in place to ensure safe use of the vegetable wash. The DM and staff were unable to verbalize manufacturer's instructions for testing and use of the vegetable wash. Staff reported they had not been trained with this and were unaware the solution needed to be tested for safety. The DM was unable to find test strips required for the process. During an interview with the RD on 2/16/23 at 3:03 pm, the RD was asked what he knew about the kitchen's vegetable/produce wash requirements and process he replied, Produce should be washed prior to being cooked. Observations and concurrent interviews with staff and the DM, and review of staff training checklists regarding use of vegetable wash showed staff were not trained in safe use and monitoring of the product to ensure it worked safely and effectively. (Cross Reference F802, F812). 2C. During an interview on 2/16/23 at 2:20 pm, the DM stated when cleaning fixed equipment, staff should use hot soapy water, then rinse, then sanitize. Three out of three staff (Cook D, Cook F, Dietary Aide B (DA B) interviewed about the process reported only using sanitizer to clean equipment (Cross Reference F812). During an interview with the RD on 2/16/23 at 3:03 pm, the RD was asked what process staff should use to clean fixed equipment (equipment that is cleaned in place and cannot go through the dishwasher), the RD stated staff should use the correct antibacterial product and use stainless steel cleaner if the equipment was stainless. Observations and staff interviews during survey showed staff cleaned equipment solely with sanitizer, when professional standards of practice for food safety require a wash, rinse, and then sanitize process (2022 FDA Food Code). (Cross Reference F802, F812) Review of a policy titled, Orientation & Competency Assessment, revised 10/18, reviewed 1/22 showed Food and Nutrition Services Staff participate in competency assessment validating knowledge and skills via testing and direct observation with competency outcomes documented .employees receive probationary and annual performance appraisals that are documented in employees Human Resources and Department files .Competency assessment is conducted .related to position-specific performance. Review of documents titled, Core Competency/Demonstration, for the Cook and Dietary Aide positions were provided by Human Resources for Cook A (4/15/19), Dietary Aide A (DA A) (4/15/19), DA B (4/12/19), Cook C (8/24/22) and DM (4/15/19). The dates indicated competency was not assessed annually per policy. The documents provided indicated staff were assessed and competent in hand hygiene/glove use, food preparation, following recipes, cleaning and sanitizing work areas and equipment, and labeling and storing food correctly, yet observations and interviews showed staff did not follow professional standards of practice. The lists also did not specify staff were trained and competent in food cooling, food allergies, or testing and use of vegetable wash.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from abuse when a physical therapy assistant (PTA) continued to work with Resident 1 after he yelled out in pain and told her to stop and again when PTA touched him on another day, after he told her to stop and had requested to no longer work with her. This resulted in an increase in pain and emotional distress. Findings: The facility policy, Abuse Prevention and Management: TCU, revised 5/2018, was reviewed. It indicated, Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident. A review of the facility's RehabCare policy, Physical Therapist Assistant Standards of Ethical Conduct, dated 4/8/16 was reviewed. It indicated, Principle #1:Physical Therapist assistants shall respect the inherent dignity, and rights, of all individuals. 1A. Physical therapist assistants shall act in a respectful manner towards each person . The facility policy, TCU Resident Rights, revised 3/2018, was reviewed. It read, Each resident and/or significant other is informed during the admission process of his/her rights as outlined in the California Standard Admission Agreement for Skilled Nursing Facilities .A copy is given to the resident or significant other. A copy of the Resident Bill of rights, read Patients shall have the right: (4) To consent to or refuse any treatment or procedure or participation in experimental research. 1. A review of the record indicated Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident 1's physician ordered physical and occupational therapy. A physician's note on 11/2/18 at 10:52 pm and a nurse's note on 11/2/18 at 11:31 pm, both indicated Resident 1 was alert and oriented. Subsequent notes also indicated Resident 1 was alert and oriented. On 11/6/18, the facility's Chief Nursing Officer (CNO) reported to the California Department of Public Health (CDPH), that Resident 1 reported a therapist pushed him too far causing exacerbated (worse) pain even when he told her to stop, on 11/2/18. During an interview on 11/14/18 at 3:30 pm, Rehab Director (RHD) said he was told on 11/5/18, that Resident 1 didn't want to work with PTA anymore. RHD said he spoke to Resident 1 who said PTA caused him a lot of pain. Resident 1 reported PTA worked with him on 11/2 and he told her it hurt and to stop and yelled. Resident 1 also reported PTA came into his room on 11/3 when she wasn't even scheduled to work with him. RHD said he spoke with his team and told them if a resident says stop or indicates pain, stop therapy. Resident 1 reported Occupational Therapy Assistant (OTA) and Housekeeping (HSK), as well as his roommate, overheard the incidents. During an interview on 11/14/18 at 4:15 pm, Resident 1 said he had PTA as his therapist on 11/2/18. During the therapy session PTA pushed and rotated his right leg and he yelled and told her to stop. Resident 1 said PTA told him she needed to break down some scar tissue and started again and he told her to stop. He said another staff (OTA) came by and told PTA to take it easy on him because she needed to work with Resident 1. PTA took him to his room shortly thereafter. When OTA came into his room Resident 1 told her he didn't want to work with PTA again. Resident 1 said PTA came back into his room later that evening and said she returned even though she was off duty, because she was waiting for a ride. During an interview on 12/19/18 at 2 pm, Occupational Therapist (OT) said she was between patients on 11/2/18, when PTA asked if she could hold Resident 1's gait belt. She said PTA was on the floor turning Resident 1's ankle. Resident 1 said over and over, that it hurt, but didn't say stop. She said she was with Resident 1 and PTA for five minutes at the most on 11/2/18. She said he walked about 15 to 20 feet and sat down in his wheelchair. She said she then left and does not know what happened after that. During an interview on 12/6/18 at 12:50 pm, OTA said, on 11/2/18, she heard Resident 1 yell and she saw him standing and PTA on the floor tying to help him move his leg. She told PTA to be careful with his leg and told her Resident 1 had no flexion in his ankle due to a prior injury. She said PTA just ignored her and continued on the floor. OTA said she walked away to work with another resident and does not know how much longer PTA worked with Resident 1. Later that afternoon when she went to work with Resident 1 he said he had more pain and was unable to do occupational therapy. She confirmed her note, patient upset may be leaving facility. She said he was angry with the PTA and she told him he could change to another therapist. 2. During an interview on 11/14/18 at 4:15 pm, Resident 1 said the next day, on Saturday (11/3/18) PTA came back into his room and started working on his leg and rolling his hip outward while he was in bed. He said he put on his call light and a housekeeper was present and he asked her to get help. Resident 1 said the charge nurse (CN) came in and he asked her to tell PTA to stop. CN asked PTA if she was assigned to work with Resident 1 that day and PTA said no. CN asked PTA two or three times to leave the room, before PTA did so. Resident 1 said he had been taking just his regular pain pills before this happened, but his doctor had to order two pain shots for him because of this incident. Resident 1 said his doctor also ordered x-rays. He said he thought this caused a setback and he didn't think he was back to where he was before that day (11/2/18). Resident 1 said he understood PTA no longer worked at the facility and he was afraid she might come in at night to his room and hurt him. A review of the record indicated a note, dated 11/6/18 that read, notified MD of patient complaint of right leg pain and concern about previous therapist session. New order for x-ray and MRI of right hip and to send report to Ortho Dr. The Ortho Dr. wrote in a note, dated 11/9/18, x-rays today show no significant change. A review of the Medication Administration Record [REDACTED]. During an interview on 12/6/18 at 11:15 am, Resident 2 said he was Resident 1's roommate. He said PTA came into their room on 11/3/18 and worked on Resident 1's leg while he was in bed. Resident 1 told her to stop, then CN came in and told PTA to leave the room. Later, Resident 1 said PTA had hurt him. During an interview on 12/19/18 at 2 pm, OT said she worked with Resident 1 on 1/5/18, and he talked to her about what happened, on 11/2 and 11/3/18, and she then reported it to the RHD. OT was told by Resident 1 that PTA went back into his room around 6 pm on 11/2/18 and said she was waiting for a ride home and worked with him even though he told her to stop. Resident 1 also said PTA went into his room on 11/3 and started moving his leg and continued until the charge nurse came into his room. During an interview on 12/6/18 at 10:35 am, CN said she was asked to go in and speak to Resident 1 who told her PTA overworked him and he no longer wanted to work with her. She told him they could get another therapist to work with him. PTA then came in and tried to talk to Resident 1 but he didn't want to listen to her so she told PTA to leave the room. CN said Resident 1 complained to her that he was in more pain because he was overworked. She said she called his physician and got more pain medication ordered and gave him an ice pack. During an interview on 12/6/18 at 2 pm, HSK said she knocked before entering the room on 11/3/18 and saw PTA moving Resident 1's leg and telling him to use ice to decrease the inflammation. Resident 1 told PTA to stop moving his leg but PTA continued to touch his leg and did not stop. She said CN then came into the room and told PTA to leave. During an interview on 12/6/18 at 1:20 pm, RHD said therapists observe for pain, as well as listen to the patient, and if a patient tells you to stop, you're causing pain or yells out, then you need to stop.

Based on observation, interview, and record review, the facility failed to prevent an avoidable fall with injury when Certified Nurses Assistant (CNA) 5 failed to provide Resident 1 with the necessary level of assistance during toileting and walking. This failure resulted in Resident 1 falling, hitting her head on a bedside table, and incurring a skin tear to her hand, neck and pelvic fractures, prolonged hospitalization , a diminished quality of life, and had the potential to result in paralysis or death. Findings: On 9/26/13 at 4:04 pm, the Department was notified by the facility that Resident 1 had sustained injuries from a fall on 9/25/13 at 9:20 pm. Resident 1's record was reviewed on 10/9/13. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a document titled, "Patient Transfer Status,'' dated 9/3/13, located in Resident 1's room, Room 143, indicated the types of activity to be utilized when Resident 1 was ambulating or transferring from one area to another. This document instructed the care giver to provide the following levels of assistance: Standby Assistance (SBA) for peri-care (cleansing after toileting); Contact Guard Assistance (CGA) for toilet transfers; and Minimum Assistance (Min A) for pant management (pulling pants up and down). Review of the facility's definitions for levels of assistance provided by staff to residents included: "Min A, expect to do about 25% of the work; CGA, have a hand on the patient, do not need to lift; SBA, this means stand RIGHT next to the patient...not on the other side of the chair or bed. They (patient) may lose balance." Review of a Care Plan, developed 8/12/13 and last revised 9/6/13, titled, "Potential for fall and/or injury" indicated that Resident 1 was at high risk for falls, had gait or balance problems, used assistive devices, had left sided weakness, and poor safety awareness. The intervention section instructed the care giver to assist with transfers, assist with toileting, keep resident in visual range when using the toilet, and utilize physical therapy and occupational therapy for evaluation and treatment, high risk interventions, as indicated. Review of the facility's Minimum Data Set (MDS) assessment, dated 9/9/13, indicated that Resident 1 had a Brief Interview Memory Score (BIMS) of 15 which meant that her ability to remember and understand was intact. The assessment identified that Resident 1 required extensive assistance (physical assistance from staff) for Activities of Daily Living (ADLs) for transfers, mobility, dressing, and toileting, Min A with hygiene, and supervision with eating. Review of a document titled, "ADL Protocol," dated 9/6/13, indicated that Resident 1 required CGA for standing and toileting with the front wheel walker, staff was to give the resident time to wipe herself, and provide Min A for peri-care, after a bowel movement. Review of a document titled, "Falls Investigation Worksheet," dated 9/25/13, indicated that Resident 1 required SBA, and CNA 5 was located behind the resident. Resident 1 complained of neck, head, and left hip pain after the fall. Recommendations/interventions for Resident 1, directed, "When assisting this patient, walk side by side and have hand on her pants or arm..." The section for the Licensed Nurse Name was left blank. The sections for the Investigator signature and title were left blank. During an interview conducted on 10/9/13 at 11:15 am, Physical Therapist (PT) 3 stated that she had worked with Resident 1 frequently. PT 3 stated that Resident 1 was anticipating discharge home within a couple of days to the care of her family (unsafe to go home alone due to fall risk), was very motivated to improve her strength, used a walker, and was making great gains, but was still having problems with loss of balance. PT 3 stated that Resident 1 was not impulsive, followed directions, and was compliant with her care. PT 3 stated that care givers were instructed to provide SBA with walking, standing right next to the resident in case of loss of balance. PT 3 stated that the Patient Transfer Status document was placed in Resident 1's room to instruct care givers how to assist Resident 1 with mobility and activities of daily living, further stating that Resident 1 still had problems with stumbling. On 10/17/13 at 7:20 am, during an interview with Resident 1's family member (FM 2), FM 2 stated that Resident 1 was [AGE] years old and had been in great health and driving, prior to suffering a stroke, which was the reason she was in a rehabilitation facility. FM 2 stated that Resident 1 had told him that she was not assisted back to bed, and that he felt the facility staff were neglectful in Resident 1's care when she fell on [DATE]. FM 2 stated that there were times when he visited that there did not seem to be enough help and Resident 1 expressed her fear of the night shift because of lack of help. FM 2 stated that Resident 1 had sustained a broken neck and pelvis which was diagnosed at the hospital she was taken to, after her fall. FM 2 stated that Resident 1 was currently recuperating at a different facility and that her level of function was less that before the fall. On 10/17/13 at 8:45 am, during an interview with Resident 1, she stated, "I was coming out of the bathroom on my way back to bed." She stated that CNA 5 was in the room, but was not near her. Resident 1 stated that she was in the bathroom unassisted and unsupervised, and her pants were not pulled all the way up after she used the toilet. She states that as she walked toward her bed, she "started to topple and fall over and I hit my head on the bed and I felt pain in my neck and hip. A nurse who came in the room after my fall commented that my pants were not pulled all the way up." Resident 1 stated that after her fall, she was put back to bed, and then sent to the hospital some time after. Resident 1 stated that she currently was at another facility for recovery from the fall, had a neck brace, still had pain in her neck and pelvis, and required someone to cut her meat, which she was able to do before the fall. On 10/24/13 at 1:55 pm, during an interview, Resident 8 stated she was Resident 1's roommate in Room 143 when Resident 1 fell . Resident 8 stated she saw Resident 1 come out of the bathroom, and when she fell , saw CNA 5 behind Resident 1. Resident 8 stated "All of a sudden, Resident 1 fell over on her side. CNA 5 could not grab her." On 10/24/13 at 9 am, during an interview, Staff 6 (a licensed nurse) stated that on the evening of 9/25/13 at approximately 9 pm, a crash was heard from one of the resident rooms. Staff 6 ran down the hall to Room 143 and found Resident 1 lying on the floor on her left side, between Bed A and the bedside table. CNA 5 was standing at the foot of Bed A. After Resident 1 was assessed by her nurse, Staff 6 assisted in lifting Resident 1 back to bed. Staff 6 said that they had taken care of Resident 1 many times and always used CGA with her because she would trip at times when walking. Staff 6 said they would always hold on to the back of Resident 1's pants to ensure she did not fall. On 10/24/13 at 9:45 am, during an interview, Staff 7 (a licensed nurse) stated that on the evening of 9/25/13, Resident 1 had turned her call light on for assistance with going to the bathroom. Staff 7 stated that CNA 5 responded to Resident 1's call light, did not stay in the room by Resident 1 during toileting. Staff 7 had to instruct CNA 5 to not leave Resident 1 alone and return to Resident 1 to assist her because of her unstable gait. On 9/25/13 at approximately 9 pm, Staff 7 heard a crash from a resident room, ran down to hall to respond, and was "upset" to find Resident 1 in Room 143, lying on the floor with her pants at upper thigh level, injured. Staff 7 stated she had taken care of Resident 1 several times and always used CGA during walking because Resident 1 is unsteady at times, and that Resident 1 could not stand up without assistance much of the time, and struggled to stand. In an interview conducted on 10/24/13 at 11:30 am, CNA 5 explained that 9/25/13 was her first night back to work after a two week vacation. CNA 5 was asked to define SBA, CGA, and Min A. CNA 5 stated that "SBA is when you stand next to the patient, CGA is when you have your hand on the patient, and Min A is like SBA, but only more awareness." CNA 5 added that for SBA, "basically, you have to be by them in case they get dizzy." When asked about Resident 1's fall on 9/25/13, CNA 5 stated that on 9/25/13, she did not provide assistance to Resident 1 when she went in or came out of the bathroom, did not assist Resident 1 with peri-care, that Resident 1's pants were around her upper thighs, not pulled all the way up after toileting and when she walked out of the bathroom unassisted, and that when Resident 1 started to fall, she (CNA 5) could not grab her, demonstrating for the surveyor her position in proximity to the Resident 1 at the time of the fall, which was observed to be more than an arms length away, not right next to the resident. On 10/24/13 at 3:15 pm, Staff 8 (a PT) stated that SBA is a type of assistance that requires the care provider to be right next to the resident with arms encircling the resident, but not touching. This allows the care provider to detect quickly when the residents leans so that the resident can be re-balanced to have position corrected. Staff 8 stated that Resident 1 was a high fall risk due to unsteady walking, and was to be provided CGA during toileting. On 10/24/13 at 4:15 pm, Staff 9 (an Occupational Therapist) stated that being two feet, even 1 foot, away from the resident would not be providing SBA, and it would be impossible to correct imbalance from that distance or catch someone during a fall. On 10/24/13 at 5 pm, Staff 10 (a PT) stated that if SBA or CGA had been provided to Resident 1, she would not have fallen. Staff 10 stated that being any distance away from the resident would not be provision of SBA.

Based on interview and record review, the facility failed to ensure that one of ten sampled residents (Resident 6) maintained acceptable parameters of nutritional status and weight when: The Registered Dietitian (RD) failed to complete a comprehensive assessment and add additional interventions when the resident lost more than ten pounds in one week; There was a delay in the implementation of a physician's orders [REDACTED]. There was inconsistent documentation regarding how much of the ordered supplement that the resident consumed; the facility had not ensured adequate intake of the ordered supplement; The care plan was not followed regarding dietary preferences; and A referral for dentures was not made. (Refer to F 250) The above failures resulted in and/or contributed to severe weight loss and placed Resident 6 at risk for continued weight loss and [MEDICAL CONDITION]. The Centers for Medicare and Medicaid Services parameters for evaluating significance of unplanned and undesired weight loss include, at the 1 month interval, a weight loss of 5% is significant and greater than 5% is severe. Findings: A review of Resident 6's record disclosed that Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility had determined that the resident was cognitively intact and he made his own healthcare decisions. A comprehensive assessment was completed by the RD on 6/27/13. The RD's assessment showed that Resident 6 had a low [MEDICATION NAME] (body's major plasma protein) level of 2.2 (normal range 3.2-5), was consuming 25 percent of a Regular diet, had a poor appetite and was nutritionally at risk. The RD determined that Resident 6 had inadequate oral intake and chewing difficulties due to having no upper dentures or teeth. This assessment included estimated calorie, protein, and fluid needs, in addition to weight. The RD recommended Ensure Plus, a dietary supplement, and a change in diet from Regular to chopped with ground meat. The RD's medical nutrition therapy goals for Resident 6 included oral nutritional intake greater than 75 percent and that the resident would maintain his weight. Resident 6's weekly weights (documented in kilograms (kg, one kg equals 2.2 pounds) were as follows: Admit weight on 6/25/13 - 67.9 kg. Resident 6 was started on a dietary supplement, Ensure Plus, one can twice per day. 6/30/13 - 68.5 kg. 7/7/13 - 63.2 kg, which was a decrease of 5.3 kg. There were no additional interventions that addressed this loss of 7.6% body weight in one week. 7/14/13 - 60.7 kg, which was a decrease of 2.5 kg and an additional 3.7% body weight from the prior week. This represented a weight loss of 10% body weight in 19 days. There was a physician's orders [REDACTED]. Facility staff failed to implement this order until it was brought to their attention by the surveyor on 7/17/13. Following the resident's weight loss on 7/7/13, the RD made a note on 7/10/13 that included the following: Regular diet with ground meats and average meal consumption of 25-75 percent (less than his established goal of greater than 75 percent), Resident 6's weight on 7/7/13, and that he had lost about 5 kg; Resident 6's usual body weight was 63.6 - 65.9 kg. At the end of the RD note "encourage intake" was written. The assessment did not include [MEDICATION NAME], calorie, protein and fluid needs, or an estimate of what Resident 6 had consumed in regards to the nutritional supplement, or if the level of Resident 6's nutritional risk had changed. During an interview on 7/17/13 at 8:30 am, the RD confirmed the note on 7/10/13 documented his assessment following Resident 6's weight loss on 7/7/13. The RD stated that he did not recommend any additional interventions on 7/10/13, even though Resident 6 had lost 10 pounds. The facility's policy titled, "Dietitian Notification of High Nutritional Risk Patients," last revised 5/2010, was reviewed. It read as follows: Patients who are considered at high nutrition risk include, but are not limited to, those who have significant weight change of greater than five pounds in 30 days, and [MEDICATION NAME] less than or equal to 2.5. Patients at high risk nutritionally are monitored closely by the clinical dietitian and assessed as the patient's clinical status warrants. The facility's policy titled, "Nutrition Assessment and Care," last revised 8/2012, read as follows: The clinical dietitian completes a comprehensive assessment for patients who experience a significant negative decline of overall condition. The RD completed another evaluation of Resident 6 on 7/15/13, and noted the additional wight loss of 2.5 kg (5.5 pounds) since the prior week, and recommended that the Ensure Plus be increased from one can twice per day to three times per day. A nurse received an order from Resident 6's physician to increase the Ensure Plus to three times per day with meals on 7/15/13 at 1:45 pm. This order was noted at 1 am on 7/16/13 and a 24 hour chart check was initialed as having been completed. During an interview on 7/17/13 at 7:30 am, Dietary Aide (DA) J confirmed that Resident 6 was receiving Ensure two times per day not three. She provided the menu for 7/16 and 7/17/13, that showed that Ensure Plus was to be given at breakfast and dinner, not at lunch. DA J stated that if there was a new order for a supplement or diet change the nurse would enter the order into the computer and the dietary department would carry out that order. If the nurse did not enter the order then the Dietary department would not be notified. DA J stated they had food preferences on three residents in the facility, but did not have a food preference list for Resident 6. On 7/17/13 at 7:40 am, during an interview, Resident 6 stated that he received only two cans of Ensure Plus the prior day, one at breakfast and one at dinner. During an interview on 7/17/13 at 8 am, Admin Staff A confirmed that the order to increase the Ensure had not been entered into the computer by the nurse who noted the order. The documentation regarding how much Ensure Resident 6 consumed each day was reviewed and found to be inconsistent. On some days no Ensure was documented as being consumed while on other days it was documented that he consumed both cans. During an interview on 7/17/13 at 8:30 am, RD stated that to determine how much of the supplement the resident consumed, he would ask the resident and review the documentation. RD stated they were aware of the problem with inconsistent documentation by the nursing staff. RD was asked if he reviewed food preferences with Resident 6. RD stated that he told Resident 6 about the write in option on the menu. RD stated that sometimes dietary staff would check preferences. A review of the facility's Nutrition care plan, dated 6/27/13, for Resident 6 included, "honor food preferences." Providing food that the resident preferred or like could improve their oral intake. During an interview on 7/17/13 at 4:15 pm, Admin Staff A confirmed that the documentation regarding the amount of Ensure that had been consumed by Resident 6 was inconsistent. During an interview on 7/18/13 at 9:45 am, the Director of Staff Development (DSD) stated that when a nurse noted an order that meant that the order had been communicated to the appropriate person or entity. DSD said it was their practice to do a daily 24 hour chart check. DSD explained that was when a nurse reviewed all orders from the prior day to make sure no orders had been missed.

Based on interview and record review, the facility failed to prevent an avoidable fall with injury when one of two sampled residents (Resident 1) was left alone and unsupervised in the bathroom. This failure resulted in Resident 1 falling and sustaining a broken right leg, skin tear, and pain. Findings: Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated 3/18/12, reflected that Resident 1 was severely cognitively impaired and required physical assistance with toilet use, transferring, and walking. During an interview with Administrative (Admin) Nurse A on 4/4/12 at 10:15 am, she reported that Resident 1 had been assisted into the bathroom by Certified Nursing Assistant B (CNA) on 3/22/12 at approximately 2:45 pm. Resident 1 requested that CNA B give her some privacy and so after situating Resident 1 on the toilet, CNA B closed the bathroom door, leaving it ajar so that she could monitor Resident 1. While Resident 1 was on the toilet, CNA B responded to another resident who had cried out for assistance. CNA B went to assist the other resident during which time another staff member found Resident 1 on the floor. Resident 1 complained of right hip and leg pain and had a skin tear on her right elbow. During an interview with Resident 1 on 4/4/12 at 10:30 am, she was unable to recall the event but did report that her pain is being controlled following breaking her leg. Resident 1's Fall Care Plan, initiated on 3/11/12, indicated that Resident 1 had the potential to fall and/or sustain an injury due to gait (walking ability) and/or balance problems, weakness, cognitive impairment and poor safety awareness. The care plan indicated that Resident 1 was considered a high fall risk, and therefore, would be identified as a high risk by wearing a yellow armband. During an interview with CNA B on 4/4/12 at 5:30 pm, she reported that she was assisting Resident 1 into the bathroom on 3/22/12. Resident 1 was wearing a yellow arm band, which indicated she was a high fall risk. CNA B explained that after she got Resident 1 onto the toilet, she requested some privacy. CNA B stated that she closed the bathroom door, but kept it cracked so that she would be available as needed. CNA B stated at this time, the resident next door started yelling out for assistance and she left Resident 1 unsupervised to respond to what CNA B explained as an urgent call for assistance. CNA B reported that she had been out of visual contact with Resident 1 for less than 5-minutes when she heard another staff member yell for assistance. That staff member had found Resident 1 on the floor. Resident 1 sustained a skin tear on her elbow and was complaining of pain in the right leg. CNA B reported that Resident 1 was transferred to the hospital after an x-ray showed that she had fractured her leg. CNA B acknowledged that she should have never left Resident 1 unsupervised. During a review of the facility's policy and procedure, titled, "Fall Program, TCU" revised 3/12, read, "High Risk Fall Precautions; place a yellow armband to identify as high fall risk... Maintain visual observation when resident is in the bathroom or shower..."

Based on dietetic services observations, dietary staff interview, and dietary document review, the facility failed to ensure a safe and sanitary dietetic services environment evidenced by: 1. The facility failed to ensure a safe dietetic service environment, free from immediate fire danger, when dripping oil from the deep fryer unit (a unit filled with oil for cooking of food by submerging in oil at a high temperature) was observed collecting on the bottom of the unit, directly next to a lit pilot light. Due to the facility's failure to conduct a thorough inspection and identify that fixed equipment in the kitchen, a deep fryer unit, was not safe for use, placing the facility at risk for fire, an Immediately Jeopardy was declared on 2/16/12 at 8:48 am, with Dietary Service Supervisor (DSS) and Cooks G and H. 2 a. The facility failed to thaw meat under sanitary conditions when raw meat was observed thawing in the refrigerator on a middle shelf above prepared food. b. The facility failed to ensure a food preparation area was not contaminated when a dietary aide used a gloved hand to open a trash can and then continued to prepare food items, without changing gloves or hand washing. c. The facility failed to ensure that the dishwasher grease collection device (Big Dipper) was cleaned, according to manufacturer's recommendations. d. The facility failed to ensure that the kitchen floor was clean in the dish washing area. e. The facility failed to ensure that the cooks rack, which had dried food items stored on the bottom shelf, was clean. These failures presented a fire danger to facility residents, staff, and visitors and an unsanitary environment and had the potential to cause the spread of bacteria and foodborne illness (food poisoning). Findings: 1. On 2/16/12 at 8:30 am, the kitchen fryer was observed. The fryer was in use and the oil was visibly hot (boiling). After use at 8:32 am, the fryer unit door was opened and observed with Cooks G and H and the Dietary Service Supervisor (DSS). There was a dark black/brown sticky substance with a light colored oily substance on the interior base of the unit. Cook H stated that the bottom of the fryer unit was difficult to clean because of the design of the unit and the limited space inside the cabinet. Further inspection of the interior of the fryer cabinet revealed there was a pooled collection of an oily substance extending from the front to the back of the cabinet that was 25 inches in length and eight inches wide. The pilot light was lit and located 5 inches from the pooled collection of oily substance. Wires, gas line, and four chambers for heat/flame were also observed inside the cabinet. During this observation, it was noted that there was an active drip of the oily substance occurring from within the fryer unit to the cabinet bottom. Cooks G and H stated that the observed dripping oil was coming from a leak in the upper fryer unit. Cook H stated that the puddle of oil near the open flame created a risk for fire. Due to the facility's failure to identify that fixed equipment in the kitchen, a deep fryer unit, was not safe for use, placing the facility at risk for fire, Immediate Jeopardy was declared on 2/16/12 at 8:48 am in the presence of the DSS and Cooks G and H. Cook H then turned the gas line to the pilot light off, turning off the pilot light flame in the fryer cabinet. In an interview on 8/16/12 at 8:50 am with Cook G, he stated that the fryer unit was drained, cleaned, and new oil added to the upper compartment weekly, and that the last time the oil was changed was 2/15/12. He stated that he had not looked at the base of the unit and only looked at the front section of the fryer unit and that the fryer unit had not been inspected for at least one month and did not know for how long the pooled oil was present. In an interview with the Quality Assurance Nurse (QAN) and Maintenance Supervisor (MS) on 2/16/12 at 9 am, the MS stated that there had been a previous repair to the fryer unit. The most recent work order was provided for review and confirmed that on 1/30/12, staff had submitted a repair request related to the fryer. Documentation on the work order, dated 1/31/12 indicated that the high temperature lock out had been replaced. The QAN and MS said that inspection of the fryer was not included as part of the facilities fire safety inspection, which is conducted by the MS, and not part of the QA review of the kitchen. On 2/16/12 at 9:10 am, the QAN and the MS presented a plan of correction to the survey team which included the following: (1) The fryer unit will not be used until repairs and verification of the repair is accomplished. (2) The fire safety officer will add the fryer unit as a part of the inspection. (3) Quality Assurance review done quarterly will include observation and review of the fryer unit. (4) Dietary staff who clean the fryer unit weekly will be in-serviced immediately. On 2/16/12 at 9:25 am, the QAN and MS were informed that the Immediate Jeopardy was abated. 2a. On 2/13/12 at 8:30 am, the walk-in refrigerator was observed with the DSS. There was raw meat thawing in a plastic container filled with water on a middle shelf above a large pan with bacon covered with plastic. The DSS acknowledged the above finding and stated that raw meat/protein items should be stored and defrosted below other food items. b. On 2/16/12 at 9 am, Dietary Aide (DA) J was observed wearing gloves, opening cartons of milk and pouring the milk into cups. DA J used a gloved hand to open a trash can, toss empty cartons into the trash, and then continued to prepare food items. On 2/16/12 at 10 am, DA J stated that when she opened the trash can, she had tried to use the side of her arm to open the trash can lid. On 2/16/12 at 10:10 am, QAN stated that a different trash can, that did not require staff to use their hands to open the lid, was needed. c. On 1/21/12 at 8:50 am, the kitchen dishwasher area was observed. Dietary Aide (DA) I stated that the dishwasher water went through a grease collection unit (Big Dipper) that had a basket to collect solids, and then the liquid went through an outlet through a rubber drain where the greasy liquid was then collected into a container. DA I stated that the basket contents was emptied daily into the trash, and collection container was emptied daily into a recycling barrow. He stated that the entire unit was cleaned twice weekly. DA I stated that twice weekly, when he cleaned the Big Dipper unit, that he would "scoop" the collected greasy fluid out with a bucket, "pour about a 1/2 cup of sanitizer or bleach, then flush the unit with warm water from a hose." DA I stated he "did not remove any of the parts in the Big Dipper when the unit was cleaned twice weekly." DA I demonstrated how the Big Dipper was opened. When the unit was opened there was a very strong foul odor from the open unit. The DSS provided the manufacturer's instructions on how the Big Dipper was to be maintained. The undated document titled, "Big Dipper system Maintenance," instructed staff to clean the: wiper blades, grease outlet, sump pump, rubber drain. On 2/21/12 at 9 am, DA I stated that he had cleaned the unit for several years and did not remove or clean the Big Dipper's wiper blades, outlet and or drain. d. On 1/25/12 at 10:10 am, the kitchen floors were observed with the QAN and the DSS. The dishwasher floor area had an accumulation of dirt and dust particles. The QAN acknowledged the above finding and stated the floor needed to be cleaned in the dishwasher room area. e. On 2/13/12 at 9:40 am, the cooks rack by the oven was observed with the DSS. The rack had dried food items stored on a tray that was on the bottom shelf. The tray and entire rack was sticky and had a layer of dust on all surfaces. The DSS acknowledged the above finding and stated that the rack needed to be cleaned.

Based on observation, interview, and record review, the facility failed to prevent accidents and three avoidable falls by not implementing interventions, including adequate supervision, for three of eleven sampled residents (Residents 7, 8, and 11). The facility failed to prevent an avoidable fall with injury when 1 of 11 sampled residents (Resident 8) was left alone in the bathroom, fell , sustaining a head injury, skin tear with bleeding, and pain. The facility failed to prevent two avoidable falls without apparent injury when footwear and a bed alarm were not applied, per policy and care plan, for 1 of 11 residents (Resident 11). The facility failed to prevent an accident with no apparent injury for 1 of 11 residents (Resident 7) when footwear was not applied, per policy. These failures had the potential to cause the residents unnecessary injury and an inability to obtain their highest practicable level of well-being. Findings: 1. Resident 8 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment), dated 1/27/12, reflected that Resident 8 was cognitively intact, had paralysis on one side of the body, and required two people to physically assist her with toileting. During an observation and interview with Resident 8 at 11 am on 2/15/12, she stated that Certified Nurses Aide (CNA) F had instructed her to, "hold on to the grab bar" and left her alone in the bathroom to get more gloves. Resident 8 stated, "I could not bear my weight that long and became weak, I fell forward and hit my forehead on the bathroom door which left a bump about the size of a nickel, it hurt, and I got a skin tear on my right wrist." During an interview at 3:20 pm on 2/21/12, CNA F confirmed that he had left Resident 8 on the toilet unsupervised, while he went to retrieve gloves, and that she fell off of the toilet. CNA F stated that while he was out of the room he heard Resident 8 fall, but had toileted her by himself, as opposed to the two person transfer that was required, and there was no one in the bathroom to help her. CNA F stated that he returned to the bathroom and found Resident 8 lying on her left side on the bathroom floor, and her right wrist was bleeding. During an interview with the Quality Assurance Nurse (QAN) at 10:55 am on 2/21/12, she confirmed that Resident 8's fall was avoidable and resulted in injury. On 2/21/12 at 3:50 pm during an interview, the Director of Nurses (DON) confirmed that nursing staff had not provided ongoing assessment of Resident 8's skin tear, there was no order to treat it, and it was not care planned, that Resident 8 had not been assessed from head to toe after she fell and there was no evidence of close monitoring for changes including late effects of the fall, the Morse Fall Score was not reassessed and did not reflect that Resident 8 fell , there were no neurological assessments, and monitoring every two hours for 24 hours, for bleeding, was not done. The DON confirmed that Resident 8 required two staff to assist with toileting. 2. Resident 11 was admitted to the facility on [DATE] and discharged from the facility on 1/27/12. Resident 11's [DIAGNOSES REDACTED]. The pre-admission intake, dated 12/19/11, indicated that Resident 11 was a "FALL RISK." Review of the Fall care plan, dated 12/19/11, instructed staff to "increase supervision of Resident 11, use a bed alarm, a low bed, and place fall mat on the floor." The 12/26/11 MDS, indicated that Resident 11 was unable to walk, required extensive assistance for transfers and care. The 12/26/11 nurses flow sheet indicated that Resident 11 was a "high risk for falling" (score of 55) and to implement "high risk precautions." a. The 12/27/11 transdisciplinary progress record read, "discussed fall precautions/reporting. She had an assist to the ground on 12/26/11. Had socks on instead of non-skid slippers. CNA educated on need to assure non-skid socks are on." b. The transdisciplinary progress record, dated 12/28/11 at 4 pm, read, "CNA found resident on the floor at the end of the bed. Bed alarm was not on... no apparent injuries." The record indicated that Resident 11 had two additional falls. On 1/14/12, Resident 11 was found on the floor by the bed and on 1/19/12, Resident 11 "slid off shower bench while dressing." The facility's policy titled, "Fall Program", revised 6/11, Procedure 2, "Universal Fall Precautions", directed the following: "Initiate and maintain the following universal fall precautions for ALL patients; "Ensure footwear fit appropriately and are non-skid and used properly." Procedure 3, titled, "High Risk Fall Precautions" instructed staff to, "Verify all universal precautions are in place." On 2/21/12 at 10:55 am, the QAN verified that Resident 11's falls on 12/26 and 12/28/11 were both avoidable and that Resident 11 fell when not provided appropriate footwear, and again, when the bed alarm was not on Resident 11, as care planned. 3. Resident 7 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The MDS, dated [DATE], reflected that Resident 7 was cognitively intact and required one person to physically assist her with transfers. On 2/15/12 at 3 pm, Resident 7 was interviewed. Resident 7 described that her CNA was helping her transfer from her bed to her wheelchair, but the CNA had not noticed that the non skid portion of the sock on Resident 7's right foot was not on the bottom of her foot, but rather was on the top. Resident 7 stated, "when she got me up, I slipped and my right knee bent, but I was not hurt." On 2/15/12, Resident 7's medical record was reviewed. Resident 7's Fall care plan, dated 1/29/12, revealed that she had, "lost her balance when her sock slipped and went down on her right knee." The MDS Care Area Assessment Documentation Notes for Falls, dated 2/2/12, described, "She did have a fall on 1/29/12 in her room. She was up and her sock slipped down causing her to slide to her knee. No injury was caused." There was no documentation in the nurses notes or progress notes that Resident 7 fell or that the physician was notified. On 2/15/12, the facility's policy titled, "Fall Program", revised 6/11, was reviewed. Procedure 2, titled, "Universal Fall Precautions" directed, "Initiate and maintain the following universal fall precautions for ALL patients: F. "Ensure footwear fit appropriately and are non-skid and used properly." During an interview with the QAN at 10:55 am on 2/21/12, she confirmed that Resident 7 fell and acknowledged the above findings.