Does ST JOHN KRONSTADT CONVALESCENT CENTER have any serious inspection findings?

Yes, ST JOHN KRONSTADT CONVALESCENT CENTER has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 23 total deficiencies from recent inspections.

What are the staffing levels at ST JOHN KRONSTADT CONVALESCENT CENTER?

ST JOHN KRONSTADT CONVALESCENT CENTER has a five-star staffing rating from CMS with 0.62 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is ST JOHN KRONSTADT CONVALESCENT CENTER located?

ST JOHN KRONSTADT CONVALESCENT CENTER is located in CASTRO VALLEY, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does ST JOHN KRONSTADT CONVALESCENT CENTER have?

ST JOHN KRONSTADT CONVALESCENT CENTER has 49 certified beds.

Who owns ST JOHN KRONSTADT CONVALESCENT CENTER?

ST JOHN KRONSTADT CONVALESCENT CENTER is a non profit - corporation facility and operates independently (not part of a chain).

ST JOHN KRONSTADT CONVALESCENT CENTER

Name: ST JOHN KRONSTADT CONVALESCENT CENTER
Address: 4432 JAMES AVENUE, CASTRO VALLEY, CA, 94546, US
Telephone: (510) 889-7000
Rating: 4.0

4432 JAMES AVENUE, CASTRO VALLEY, CA 94546 · (510) 889-7000

Non profit - Corporation 49 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

61/100

#466 of 1155 in CA

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Last Inspection: June 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

St John Kronstadt Convalescent Center has a Trust Grade of C+, which means it is slightly above average but not outstanding. It ranks #466 out of 1155 facilities in California, placing it in the top half of nursing homes statewide, and #44 out of 69 in Alameda County, indicating that there are only a few better local options. The facility is improving, with a reduction in serious issues from six in 2024 to just one in 2025. Staffing is a strong point, earning a perfect 5/5 stars and a turnover rate of 24%, which is significantly lower than the state average, suggesting experienced staff who are familiar with residents’ needs. However, the facility has received $11,170 in fines, which is concerning as it reflects some compliance issues, and there have been critical findings related to food service oversight, including inadequate nutrition management and failure to provide palatable meals, which could affect residents' health and satisfaction.

Trust Score: C+
In California: #466/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 24% annual turnover. Excellent stability, 24 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: $11,170 in fines. Higher than 56% of California facilities. Some compliance issues.
Skilled Nurses: Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 23 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★★★

5.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 6 issues

2025: 1 issues

The Good

5-Star Staffing Rating · Excellent nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (24%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (24%)
24 points below California average of 48%

Facility shows strength in staffing levels, quality measures, staff retention, fire safety.

The Bad

Federal Fines: $11,170

Below median ($33,413)

Minor penalties assessed

The Ugly 23 deficiencies on record

1 life-threatening

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that Resident 1's alleged abuse incident was reported within the prescribed timeframes. This failure placed the Resident 1 at risk for further possible abuse incidents, mental anguish or emotional distress. This failure also resulted in the delay in the abuse investigation. Findings: During a review of Resident 1's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (memory loss and impaired decision-making capacity) and major depressive disorder (a mental disorder characterized by persistently depressed mood and loss of pleasure and interest in life). During an interview on 4/16/25 at 12:57 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/14/25 at approximately 7:30 a.m., Resident 1 was complaining of left arm pain and stated that the night shift Certified Nursing Assistant (CNA) 1 was mean and rough with her and hit her left arm. LVN 1 further stated that at around 12:15 p.m., she had observed Resident 1's left arm to be swollen so she obtained an order for left arm X-ray from the physician. LVN 1 stated Resident 1's left arm X-ray was done in the facility at around 4 p.m., and at around 5:00 p.m., the X-ray results revealed that Resident 1 had a fracture (broken bone) in her left arm. Stated at around 6:00 p.m., Resident 1 was transferred to the hospital for further evaluation. LVN 1 acknowledged she should have reported the alleged abuse accusation to the Administrator (Adm) and the Director of Nursing (DON) immediately when Resident 1 initially complained of the alleged abuse but stated she forgot to report the incident. Stated she was aware that alleged abuse with injury should be reported to the state department immediately or within two hours. During a review of Resident 1's left arm X-ray results dated 4/14/25 at 5:07 p.m., indicated: Acute minimally displaced mid ulnar diaphyseal fracture (a broken bone in the thinner and longer of the two bones in Resident 1's left forearm on the side opposite to the thumb). During a review of Resident 1's nurses progress notes 4/14/25 at 11:17 p.m., the notes indicated Resident 1 went to the hospital on 4/14/25 at 6:20 p.m. for evaluation of the pain in her left arm. The notes also indicated that the Adm was informed of the alleged incident at this time. During an interview on 4/16/25 at 3:00 p.m., with the DON, the DON acknowledged Resident 1's complaint of alleged abuse incident with injury should have reported to the department immediately or within 2 hours. During a phone interview with the Adm on 4/24/25 at 11:30 a.m., stated she only found out of Resident 1's alleged abuse incident at on 4/14/25 at 6:00 p.m. During a review of the SOC 341 submitted by the facility, the SOC 341 was faxed to CDPH on 4/14/25 at 8:15 p.m., eight hours after the left arm was observed to be swollen by LVN 1. (SOC 341 is a Report of Suspected Dependent Adult/Elder Abuse. It is a mandated reporting form used in California to report suspected abuse, neglect, or financial exploitation of elders or dependent adults). During a review of the facility's policy and procedure (P&P) titled, Abuse Protocols, revised 8/1/24, the P&P indicated, . Reporting: 1.Verbal notification to the Department of Public Health . shall be followed by an initial written notification using the SOC 341 and submitted within 24 hours of discovery .( The P&P did not mention to report an allegation of abuse with injury to the Adm of the facility and to other officials including CDPH immediately or within two hours). According to State Operations Manual, Appendix PP, Reporting Allegations, 483.12 (b): The facility must develop and implement written policies and procedures that, .483.12 (c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey agency .).( The State Operations Manual is a detailed information on regulations, policies, and procedures that facilities like nursing homes must follow to ensure compliance with federal or government requirements).

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the plan of care developed by the interdisciplinary team will be recorded on the resident care plan . Based on observation ,interview and record review, the facility failed to provide adequate supervision for one of 5 sampled residents (Resident 1) who required supervision due to physical and verbal aggression. This resulted in an altercation between Resident 1 and Resident 2, and this also had the potential to result in Resident 1 in having more altercations with other residents which can result to a serious injury. Findings: Review of Resident 2's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included mild cognitive impairment of unknown etiology (unknown cause). During an interview with Resident 2 on 12/13/24 at 12:58 p.m., stated on 11/21/24 at around 8:30 p.m., she was ready to go to bed and asked Certified Nursing Assistant (CNA)1 to turn off the light. Stated a few minutes later after CNA 1 left the room, her roommate Resident 1 went inside their room in a wheelchair and went to the light switch and turned on the lights. Resident 2 told Resident 1 to turn off the lights but Resident 1 refused and yelled No . Resident 2 then reached for the light switch, which was close to her bed and turned off the lights, but Resident 1 turned on the lights again. Resident 2 stated she stood up and walked to Resident 1 and patted Resident 1 lightly in her right cheek. Resident 1 in return, scratched Resident 2 in her left arm. Resident 2 stated she did not intend to pat Resident 1 in the cheek but stated she lost her patience. Resident 2 stated she apologized to Resident 1 later that night. Resident 2 stated, nobody saw the altercation between her and Resident 1, but she told the Social Service Director (SSD) about what happened the following day on 11/22/24 afternoon, because she felt bad about what she did. Stated she moved to another room after she talked to the SSD. Review of Resident 2's Minimum Data Set ( MDS, an assessment tool) dated 12/4/24, indicated she had a brief interview for mental status or BIMS of 15 (BIMS score of 13 to 15 indicates cognition is intact). The MDS indicated Resident 2 had no physical and verbal behavior symptoms directed toward others. The MDS also indicated that Resident 2 only needed supervision from the staff when moving from seated to standing position and walking ten feet in a room. Review of Resident 2's Departmental Notes dated 11/22/24 at 5:24 p.m., indicated Resident 2 mentioned to the SSD that she had an altercation with her roommate Resident 1 the previous night (11/21/24) because Resident 1 wanted their room lights on, and Resident 2 wanted the lights off. The residents disagreed verbally and then Resident 2 slapped Resident 1 and Resident 1 scratched Resident 2 which gave Resident 2 two scratches in her left arm. The notes also indicated that Resident 2 was moved to another room and the facility called the police department. During an interview with SSD on 11/10/24 at 1:39 p.m., SSD stated on 11/22/24, at around 4:00 p.m., Resident 2 told her that she had a disagreement with Resident 1 because Resident 1 wanted the lights on but Resident 2 wanted the lights off. Resident 2 stated the situation escalated, and Resident 2 lost her temper and slapped Resident 1 in the face, and Resident 1 scratched Resident 2 in her left arm. SSD stated Resident 2 said she was sorry for what happened because she reacted to what Resident 1 was doing when she kept turning on the lights. SSD stated Resident 2 was moved to another room. SSD stated Resident 2 obtained 2 scratches in her left arm and Resident 1 had no injuries. During an observation on 12/10/24 at 11:53 a.m., Resident 1 was seen wheeling herself around the facility's hallways repeatedly and independently in a wheelchair unaccompanied by staff. Review of Resident 1's indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills). Review of Resident 1's MDS dated [DATE], indicated BIMS of 4 (BIMS score 0 to 7 points indicates severe cognitive impairment). The MDS indicated that Resident 1 had physical and verbal behavioral symptoms directed toward others daily. The MDS also indicated that Resident 1 only requires setup or clean-up assistance with her wheelchair, meaning a helper will set up the wheelchair or clean up after use. The MDS further indicated Resident 1 was independent once sitting in the wheelchair and had the ability to wheel herself for at least 150 feet in corridor or similar space. The MDS revealed Resident 1 had wandering (travelling aimlessly from place to place) episodes. During an interview CNA 1 on 12/11/24 at 1:09 p.m., stated Resident 1 wandered around the facility, went to other residents' rooms, and sometimes took things that belonged to other residents. During an interview with the Director of Nursing (DON) on 12/13/24 at 2:16 p.m. and concurrent review of Resident 1's Departmental Notes, the notes indicated that there were three other incidents when Resident 1 had altercations with three other residents (Residents 3, 4 and 5). One incident was on 10/18/24 at 3:17 p.m., when Resident 3 reported that Resident 1 wandered in her room, and when she asked Resident 1 to leave, Resident 1 kicked her. Another incident happened on the same day of 10/18/24 at 10:11 p.m. when Resident 1 attempted to go to Resident 4's room and had a verbal altercation with Resident 4 (both of these incidents happened 35 days before the incident with Resident 2 on 11/21/24). Upon further review, Resident 1 had another verbal altercation with Resident 5 on 12/8/24 at 1:22 p.m.( happened 17 days after incident with resident 2 on 11/21/24), when Resident 1 took Resident 5's snowman decoration from Resident 5's board. The residents were separated right away on all three incidents, and no injuries were observed to the residents on all occasions. Further review with the DON of Resident 1's behavioral care plans, the DON could not find care plans that addressed Resident 1's altercations and behaviors with Residents 3 and 4 on 10/18/24, with Resident 2 on 11/21/24 and with Resident 5 on 12/8/24 . DON acknowledged a plan of care should have been developed and revised on all four altercations to monitor and prevent Resident 1's wandering and aggressive behavior towards other residents. DON also could not find Interdisciplinary Team (IDT-are an approach to healthcare that integrates multiple disciplines through collaboration) meeting notes which addressed or discussed interventions for Resident 1's altercations with Resident 2, 3, 4, and 5. During a review of the facility's policy and procedure (P&P) titled, Accidents and Incidents, revised September 2016, the P&P indicated, .Identifying Residents at Risk for Accidents: Procedure: 1. The interdisciplinary team will evaluate accident potential during admission, quarterly and annual assessments; and when a resident experiences a significant change of condition .3. Accident hazards identified by the interdisciplinary team will be recorded on the Interdisciplinary Team Notes. 4. the plan of care developed by the interdisciplinary team will be recorded on the resident care plan .

Jun 2024 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure effective medication administration and accurate accountability of a controlled substance (medications that can be easily abused and are under strict government control) when: 1. Nursing staff did not correctly prime the pen needle during the administration of insulin (medication to lower blood sugar) for one of two sampled residents (Resident 27) receiving an insulin injection. This had the potential to result in Resident 27 to not receive a full dose of insulin. 2. One of 31 sampled residents (Resident 19) received calcium and iron at the same time. This had the potential for an interaction leading to the decreased absorption of iron, and the resident not receiving the full therapeutic effect of the medication. 3. During a random controlled medication use audit, one of two randomly sampled residents (Resident 7) did not have all administered medications correctly documented on the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medication) and on the Medication Administration Record (MAR) to indicate they were administered to the resident. This failure had the potential to result in misuse or diversion of controlled medications and had the potential to make it more difficult to monitor if medication dosages need to be adjusted. Findings: 1. During an observation on 06/03/24 at 11:59 a.m., Licensed Vocational Nurse (LVN) 4 primed the insulin pen (a device used to administer medication to lower blood sugar), named Fiasp (a rapid-acting insulin) Flexitouch pen, by holding it horizontally while having the needle cap on, prior to administering insulin to Resident 27. During an observation and interview on 6/3/24 at 12:40 p.m., LVN 4 explained the insulin pen priming process by holding the pen horizontally while keeping the needle cap on and turned the pen dial to 2 units and pressed the bottom of the pen (the dose button) to prime the needle. During an interview on 06/05/24 at 01:11 p.m., the Pharmacy Consultant (PC) stated that the correct way to prime an insulin pen is to hold the pen upright, and if pen is not primed correctly, the dose could be incorrect. A review of the manufacturer's Instructions for Use, for Fiasp Flextouch, revised 6/2023, retrieved from: https://www.novo-pi.com/fiasp.pdf indicated: Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top . Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. During a review of facility's policy and procedure (P&P), titled Medication Administration Subcutaneous Insulin, dated 05/2016, the P&P indicated the pen should be held with the needle pointing upwards. 2. During a medication administration observation on 06/04/24 at 04:25 p.m., LVN 6 was observed giving Resident 19 seven medications, including a tablet of Oyster Shell Calcium (a supplement) 500 mg and a tablet of iron sulfate (to treat iron deficiency) 325 mg. A record review of Resident 19's MAR, dated May 2024, indicated the facility scheduled both the calcium and iron sulfate to be given daily at 5 p.m. During an interview with the Director of Nursing (DON) on 06/05/2024 at 11:21 a.m., DON stated her quick online research showed iron sulfate's absorption may be affected by the co-administration with calcium carbonate, and their administration should be spaced out two (2) hours apart. During an interview on 06/05/24 at 01:11 p.m. with Facility's Pharmacy Consultant (PC), PC stated Resident 19 was receiving calcium and iron at the same time. PC stated she was aware of the interaction between the two medications, made herself a note in her computer, but did not communicate with the facility because it was a minor interaction. A record review, Lexicomp, a nationally recognized drug information resource, indicated the concurrent use of calcium carbonate and ferrous sulfate would lead to Risk Rating D (meaning consider therapy modification) drug-drug interaction. Specifically, Lexicomp indicated calcium carbonate may decrease the absorption of Iron Preparations . The absorption of ferrous sulfate has been shown to be reduced by 15% to 24% with calcium carbonate. It further indicated to consider separating the doses of the two medications as much time as possible in patients who require chronic use of both agents and monitor for decreased therapeutic effects of oral iron preparations. 3: During a concurrent interview and record review with DON on 6/4/2024 at 1:46 p.m., the CDR and MAR for Resident 7 were reviewed. DON stated the records indicate that the CDR was signed when oxycodone HCL 5 mg (a pain medication with potential for abuse) was removed for Resident 7 three times: on 1/10/24, on 2/[date unclear]/24, and 2/21/24, and the medication administration was not entered on the MAR. DON stated the nurse should sign the CDR and document in the MAR when controlled medications are given. DON stated LVN 3 signed the CDR for Resident 7 on 2/21/24, but did not enter the administration on the MAR. During an interview with LVN 3 on 6/4/2024 at 4:08 p.m., LVN 3 stated she signed the Controlled Drug Record for Resident 7 on 2/21/24, and the correct procedure is to always document in the CDR and in the MAR after giving a controlled substance. During an interview with DON on 06/05/24 at 11:21 a.m., DON stated the risk to not entering controlled doses on the MAR is that it makes it more difficult to monitor if the medication is effective and to monitor if medication dosages need to be adjusted. During a review of facility's P&P titled Medication Administration Controlled Substances, dated 11/2017, the P&P indicated when a controlled medication is administered, the licensed nurse administering the medication should document the administration on the MAR.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide gender specific bathrooms to five of five sampled residents (Residents 1, 30, 32, 33 and 41). A female resident (Resident 32) shared a [NAME] and [NAME] bathroom (a bathroom that has two doors and is accessible from two bedrooms) with two male residents (Resident 30 and Resident 33) in the adjacent room. A female resident (Resident 1) shared [NAME] and [NAME] bathroom set up with a male resident (Resident 41). This failure placed Residents 1, 30, 32, 33 and 41 at risk for humiliation and discomfort. Findings: 1. During a concurrent observation and interview on 6/3/24 at 11:00 a.m., in Resident 41's room, Resident 41 was sitting in wheelchair. Resident 41 stated he shared the bathroom with a female resident (Resident 1) residing in the adjacent room. Resident 41 stated sharing the bathroom with a female resident was unacceptable. Resident 41 stated it was concerning for him as he would look bad if he happened to enter the bathroom if Resident 1 was already in the bathroom. During a record review of Resident 41's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/10/24, Section H - Bladder and Bowel of the assessment indicated Resident 41 was always continent (able to always control bladder voluntarily and/or bowels) with bowel and bladder. During an interview on 6/4/24 at 11:48 a.m. with Certified Nursing Assistant (CNA) 2, Resident 1 was observed sitting in a wheelchair in the hallway. CNA 2 stated Resident 1 was able to use the bathroom with assistance. CNA 2 stated she was aware Resident 1 shared a bathroom with a male resident (Resident 41) and that's why she preferred to take Resident 1 to the common bathroom by the dining room instead. CNA 2 stated female and male residents were not supposed to share one bathroom and she was concerned because it could cause discomfort to the residents especially the female residents. During a record review of Resident 1's Bowel and Bladder Record, dated April and May 2024, the record showed Resident 1 had multiple episodes of bowel continence. 2. During an interview on 6/4/24 at 9:28 a.m. with Resident 30, in Resident 30 and Resident 33's shared bedroom, Resident 30 stated their bathroom was shared with a female resident (Resident 32) in the adjacent room. Resident 30 stated he felt it was inappropriate for men and women to share the bathroom together. Resident 30 stated there was an incident when another resident from the adjacent room exited the bathroom and entered their room. Resident 30 stated the facility did not inform him that he would be sharing the bathroom with female residents before he was moved to this room. During a record review of Resident 30's MDS assessment, dated 4/25/24, the MDS assessment Section H - Bladder and Bowel indicated Resident 30 was frequently incontinent (able to have at least one episode of continent voiding and bowel movement) with bowel and bladder. During an interview on 6/4/24 at 09:30 a.m. with Resident 33, Resident 33 stated he did not feel good about having to share their bathroom with female residents. Resident 33 stated it was not right to have two genders share the bathroom and the facility also did not inform him about it. During an observation and interview on 6/5/25, at 9:03 a.m., Resident 32 was observed inside the bathroom with Certified Nurse Assistant (CNA 1). Resident 32 stated she did not think it was right to share the bathroom with male residents. Resident 32 stated it made her uncomfortable sharing the bathroom with male residents from the adjacent room. She also stated there were incidents when other residents or staff did not knock the before opening the bathroom door. Resident 32 stated she did not feel good about it because her privacy was compromised. Resident 32 also stated she was not informed that the bathroom will be shared between male and female residents. During a record review of Resident 32's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/21/24, the MDS assessment Section H - Bladder and Bowel indicated Resident 32 was occasionally incontinent with bladder (able to have less than 7 episodes of involuntary voiding) and frequently incontinent (able to have at least one episode of continent bowel movement) with bowel. During an interview on 6/4/24 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was the nurse caring for Residents 1, 30, 32, 33 and 41. LVN 2 stated she was aware of the shared bathrooms between male and females and that it was not appropriate because it could compromise the resident's privacy and dignity. During an interview on 6/4/24 at 12:33 p.m. with Director of Nursing (DON), DON stated the shared bathrooms had locks and signage posted on the bathroom doors to knock before entering. During an observation on 6/4/24 at 12:35 p.m. with DON, the shared bathroom between Residents 30, 33 and 32 did not have locks. The signage stating Knock before entering was only on the door for Residents 30 and Resident 33's side and not on Resident 32's side of the door. During a concurrent observation and interview on 6/4/24 at 12:40 p.m., the DON stated both the bathroom doors to the bathroom shared between Resident 41 and Resident 1 did not have a lock or signage stating Knock before entering. During an interview on 6/5/24, at 9:04 a.m. with Director of Nursing (DON), she stated she was unable to locate any records that Residents 1, 30, 32, 33 and 41 and/or their families were informed about the shared bathrooms between male and female residents when the residents were moved to their respective rooms. During a record review of the facility's Policy and Procedure (P&P) titled Dignity and Respect, last revised 5/1/22, the P&P showed the facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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3. During a review of Resident 11's Face Sheet, printed on 6/4/24, the Face Sheet indicated Resident 1 was admitted to the facility in October 2019. During a record review of Resident 11's MDS, dated 5/23/24, the MDS assessment Section GG indicated Resident 1 was totally dependent on staff for showers and needed staff's maximum assist to maintain personal hygiene and grooming. During a record review of Resident 11's Activities of Daily Living Care Plan, dated 10/17/19, the care plan showed Resident 11 had a self-care deficit due to blindness and needed limited assistance with personal hygiene. During an observation and interview on 6/4/24, at 11:56 a.m. with Certified Nursing Assistant (CNA) 2, Resident 11 was lying in the bed. Resident 11 had about two inch long and thick fingernails on his left hand. Resident 11 stated he preferred his fingernails shorter. CNA 2 stated she only filed Resident 11's fingernails because they were already too long and thick, and a regular nail clipper did not work. CNA 2 stated the nurse has been informed about Resident 11's long and thick fingernails. CNA 2 stated the risk of having long and thick fingernails could provide discomfort to Resident 11. During an interview on 06/4/24, at 12:25 a.m. with LVN 2, LVN 2 stated she was aware that Resident 11 had long and thick fingernails. She stated Resident 11's fingernails have been long and thick since last year, but they could not use a regular nail clipper. LVN 2 stated they would need a special tool to trim Resident 11's fingernails. LVN 2 stated the risk of having long and thick fingernails could lead to a skin breakdown and infection. During an interview on 6/4/24, at 12:42 p.m. with Director of Nursing (DON), DON stated she was aware that Resident 11's fingernails were long and thick. DON stated Resident 11's fingernails were approximately between 1-2 inches long. DON stated the social worker was already informed about it, but no one had come to the facility yet to trim Resident 11's fingernails. During an interview on 6/4/24, at 12:44 p.m., Social Services Designee (SSD), stated she had not set up the appointment yet for Resident 11's fingernails. During a review of facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, revised on 2/1/2017, the P &P indicated, Nail care is given to clean the nail bed and keep the nails trimmed .Policy. I. Fingernails are trimmed by Certified Nursing Assistants (CNA's), except for residents with diabetes or circulatory impairments, this includes all toenails except for high - risk residents. Note: A licensed nurse will trim high-risk resident's nails. Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 16, Resident 23, and Resident 11) received proper grooming including nailcare when: 1) Resident 16 had long sharp fingernails. 2) Resident 23 had long sharp fingernails. 3) Resident 16 had long, thick fingernails. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromise physical and psychosocial wellbeing. Findings: 1. During a review of Resident 16's Resident Face Sheet, printed on 6/5/24, the Face Sheet showed Resident 16 was admitted to the facility in November 2023 and had multiple medical diagnoses including glaucoma (a group of eye diseases that damage the optic nerve and can cause blindness) and Parkinson's disease (a progressive disease of the nervous system that affects movement). During a record review of Resident 16's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/17/24, Resident 16's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 9 out of 15, which indicates moderately impaired mental status. Review of Section GG Functional Abilities and Goals indicated Resident 16 was dependent on staff for self-care including shower and personal hygiene. During an observation and interview on 6/3/24, at 10:10 a.m., Resident 16 was lying in his bed and was scratching his arm with long sharp nails causing redness to skin. Resident 16 stated he cannot trim his nails by himself because he cannot see and has asked the facility staff to trim his nails for him, but no one has helped him so far. Resident 16 stated he would like to have his nails trimmed and short. During a concurrent observation and interview on 6/3/24 at 10:22 a.m. with Licensed Vocational Nurse (LVN)1, Resident 16's fingernails were observed. LVN 1 stated Resident 16 has long fingernails. LVN 1 stated Resident 16 is diabetic and Licensed Nurses should be trimming the fingernails. LVN 1 also stated if nails are not trimmed there is risk, that resident can scratch himself and get skin tear. During a review of Resident 16's Care Plan-Self-care deficit, dated 5/22/24, the care plan indicated to assist resident 16 in ADL (Activities of daily living, things needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). 2. During a review of Resident 23's Resident Face Sheet, printed on 6/5/24, the Face Sheet showed Resident 23 was admitted to the facility in February 2024 and had multiple medical diagnoses including cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a record review of Resident 23's MDS, dated 5/22/24, Resident 23's BIMS was 14 out of 15, which indicates intact mental status. Review of Section GG indicated Resident 23 was dependent on staff for self-care including shower and personal hygiene. During a concurrent observation and interview on 6/3/24 at 10:46 a.m., Resident 23 was lying in his bed and was noted with long sharp fingernails. Resident 23 stated he has requested the facility staff to trim his nails for him many times, but no one has helped yet. Stated he like to have short nails and cannot trim his nails by himself. During a concurrent observation and interview on 6/3/24 at 10:50 a.m. with LVN 4, Resident 23's fingernails were observed. LVN 4 stated Resident 23 has long fingernails. LVN 4 also stated licensed Nurse or Certified Nursing assistant can help resident with nails care. LVN 4 stated the risk of not trimming the nails, is that Resident 23 can scratch himself and cause bleeding and wound and dirt can settle underneath nails which can cause infection. During a review of Resident 16's Care Plan-Self-care deficit, dated 5/22/24, the care plan indicated to assist resident 16 in ADLs, including personal hygiene /showering.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and label mediations in accordance with manufacturer specifications and currently accepted professional principles when: 1. The medication refrigerator temperature was below recommended temperature range for storage of refrigerated medications. 2. The medication refrigerator temperature was not consistently monitored and recorded twice daily for seven out of seven months, from [DATE] to [DATE]. 3. The temperature log had an incorrect temperature range for monitoring. 4. Nursing staff failed to notify the Maintenance Supervisor (MS) when the medication refrigerator temperature was out of range. 5. Six (6) bottles of eyedrops and one (1) insulin pen were not correctly labeled. These failures had the potential to result in 44 residents receiving medications or vaccines of unknown effectiveness and seven (7) residents potentially receiving an incorrect or expired medication. Findings: 1. During a concurrent observation and interview on [DATE] at 10:34 a.m. with the Director of Nursing (DON), the medication refrigerator was 29 degrees (°) Fahrenheit (F). DON stated that the thermometer read 29° F and the appropriate temperature range was between 36° F and 46° F. The medication refrigerator contents included one (1) pneumovax vial (vaccine for pneumonia), one (1) Fiasp pen (a type of insulin pen), one (1) box containing five (5) Humalog Kwik pens (a type of insulin pen), one (1) Basaglar Kwikpen (a type of insulin pen), two (2) vials of TB test (used to test for tuberculosis), six (6) vials of open insulin, one (1) unopened emergency box containing one (1) vial of insulin (a medication to lower blood sugar) and one (1) vial of Lorazepam (a medication given for anxiety), one (1) vial of NPH (a type of long acting insulin), two (2) boxes of influenza vaccine (a vaccine for the flu) containing a total of 13 vials, and one (1) container of lantoprost eye drops (a medication to treat high pressure in the eye). During a review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 09/2018, the policy indicated that medications requiring refrigeration or temperatures between 36° F and 46° F should be kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log is maintained to verify that temperature has remained within accepted limits. 2. During a concurrent interview and record review on [DATE] at 10:40 a.m. with the DON, the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated the last recorded temperature of the refrigerator was 34° F on [DATE] during the night shift, and the appropriate temperature should be between 36° F and 46° F. DON stated the temperature log was supposed to be monitored twice daily. The log was not filled out [DATE], and there were four (4) missing entries from [DATE], and three (3) missing entries in [DATE]. DON was requested to provide temperature logs for four (4) additional months, from [DATE] to [DATE]. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE] to [DATE], the [DATE] log contained eight (8) missing entries and five (5) entries that were below 36° F. The [DATE] temperature log contained 12 missing entries and 44 that were below 36° F. The February 2024 temperature log had six (6) missing entries and 12 that were below 36° F. The [DATE] temperature log had eight (8) missing entries. The [DATE] temperature log had three (3) missing entries. The [DATE] temperature log had four (4) missing entries. The [DATE] temperature log (as of [DATE]) had three (3) missing entries and one (1) entry that was below 36° F. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated the temperature of the refrigerator should be monitored twice daily during NOC (night) and P.M. (evening) shifts. 3. During a concurrent interview and record review on [DATE] at 01:14 p.m. with DON, DON stated that the correct range for the refrigerator was 36° F to 46° F and the facility's refrigerator temperature log, titled Record of Refrigeration Temperatures, dated [DATE], indicated that the acceptable temperature range for the medication refrigerator is between 36° F and not greater than 41° F. DON stated the temperature range of between 36° F and not greater than 41° F is incorrect and needs to be changed. 4. During a concurrent interview and record review on [DATE] at 10:40 a.m. with DON, the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], DON stated the document indicates that if the recorded temperatures are below 36° F, MS should be notified. During an interview on [DATE] at 12:11 p.m., the MS stated he learned about the medication refrigerator being too cold today, and there had been no issues previously reported. The MS stated the temperature was 32° F when he checked it today, which is colder than the acceptable range of 36° F to 46° F. During a concurrent interview and record review on [DATE] at 3:50 p.m., Licensed Vocation Nurse (LVN) 5 stated that she entered 29° F on the temperature log on [DATE] and she does not remember if she entered it on the maintenance log. LVN 5 stated that the reason refrigerator temperatures are checked is to make sure that all the medications are in good standing and regulated well. LVN 5 stated that all issues with the medication refrigerator should be entered into the maintenance log. During a concurrent interview and record review on [DATE] at 11:21 a.m. with the DON, DON reviewed the Maintenance Request Log and stated there were no entries in the Maintenance Request Log for the dates in January and December when the medication refrigerator was recorded as being outside of range. DON stated that the expectation is that the nurses will notify maintenance and enter temperatures that are outside range in the maintenance log. DON stated that the potential consequences for the refrigerator being too cold is that the insulin and vaccines stored in the refrigerator are not supposed to be frozen, which could cause decreased effectiveness of the medications. In a concurrent record review and interview on [DATE] at 4:08 p.m., LVN 3 stated that she signed the Record of Refrigeration Temperatures twice in January ([DATE] and [DATE]) indicating that the temperature of the medication refrigerator was 32° F. LVN 3 stated that she did not notify maintenance because she was not aware that 32° F was too cold. LVN 3 stated that the form Record of Refrigerator Temperature indicates that temperatures below 36° F should be reported to Maintenance Supervisor. During a telephone interview on [DATE] at 1:11 p.m., the Pharmacy Consultant (PC) stated that she recommended that the medication kept in the medication refrigerator be replaced because there are no studies on what happens to medications when kept in that temperature range, so it is unknown what the effects would be. The PC stated that the correct temperature range for the medication refrigerator is between 36° F to 46° F. During a review of the refrigerator temperature logs, titled Record of Refrigeration Temperatures, dated [DATE], the document indicated that adequate temperature was Refrigeration: 36° F and not greater than 41° F and indicated report to Maintenance Supervisor when recorded temperatures are not adequate. 5. During a concurrent observation and interview on [DATE] at 2:25 p.m. with LVN 4 at Medication Cart #1, there were five (5) bottles of artificial tears (an over the counter product that lubricates dry eyes) with the only patient identifier as the resident room number for Residents 14, 10, 35, 17, and 13. LVN 4 stated that the risk of not having the resident name on the bottle is that there's a risk to giving the product to the wrong resident if they change rooms. LVN 4 stated that a bottle of latanoprost (a medication given to treat high pressure in the eye) eye drops, prescribed for Resident 16, does not have an open date. During a review of Lexicomp, a nationally recognized drug information resource, Lexicomp indicated the following for the storage of latanoprost: Once opened, the container may be stored at room temperature . for 6 weeks. During an interview on [DATE] at 11:21 a.m., DON stated that eyedrops should be labeled with the resident's name, room number, and date that they were opened. DON stated that a potential consequence of not correctly labeling eye drops is that the wrong eyedrop could be given to the wrong resident and a consequence of not writing open dates is that expired eyedrops could be given. In a concurrent observation and interview on [DATE] at 12:12 p.m. with LVN 2, at Medication Cart #2, LVN 2 stated there was no open date for the Basaglar Kwikpen (a type of insulin administration pen) for Resident 37. LVN 2 stated that medications should be labeled with an open date and if there is no open date there is a risk that residents could receive expired medication. A review of Lexicomp indicated the following for storage of Basaglar Kwikpen: Store in-use prefilled pens at room temperature . and use within 28 days. During a review of facility policy titled Medication Administration: Subcutaneous Insulin, dated 05/2016, the document indicated that the device should be dated after the first use.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had one resident room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied the room. This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. Findings: During an interview on 6/3/24 at 9:35 a.m. with Administrator (ADM), ADM stated the facility had a room waiver for room [ROOM NUMBER]. ADM stated room [ROOM NUMBER] had less than 80 sq ft per resident and had four resident beds. During an interview on 6/5/24 at 12:35 p.m. with the Maintenance Supervisor (MS), MS stated room [ROOM NUMBER] was the only room that had four residents. The following rooms and corresponding square footage (sq. ft) per bed were identified: Room Activity Room Size Floor Area 16 Resident room 308 sq. ft 77 sq.ft/bed During an observation on 6/3/24 at 9:40 a.m., Residents 2, 6, 7 and 42 were observed in their bed. The privacy of residents in room [ROOM NUMBER] was not impacted by shortage of space. Storage spaces were sufficient to accommodate the needs of residents. The ADM requested a continuous room waiver for the above residents' room.

Feb 2023 15 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0801 (Tag F0801)

Someone could have died · This affected multiple residents

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Based on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. The lack of a full-time, competent supervisor resulted in Food and Nutrition Services staff not having adequate training and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. In addition, when the dietitian was not full-time, frequent consultation was not provided from the dietitian to ensure Food and Nutrition Services was carried out in a safe and sanitary manner, when the dietitian went into the kitchen 1 hour a month. The lack of full-time, competent oversight of food and nutrition staff placed 34 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) which had the potential to result in death, for a facility census of 34. An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on February 16, 2023, at 10:30 a.m., in the presence of the Administrator (ADM) for not having full-time, competent oversight in the Food and Nutrition Services Department which left staff, who were not competent or with the skill sets, to carry out to carry out necessary tasks within the department. An acceptable plan of action was provided by ADM on February 17, 2023, at 1:06 p.m. The actions to remove the immediate jeopardy situation included: a contract was signed between the facility and a consulting company for a full-time Director of Food and Nutrition Services (also referred to as a dietary or kitchen supervisor); a qualified, full-time Dietary Services Supervisor (DSS 2) was hired to supervise the kitchen beginning 2/17/23 and moving forward until a permanent solution is implemented; and DSS 2 was to immediately begin in-servicing and training current dietary staff on all operational policies and procedures for the kitchen including, but not limited to the following: general operating policies for the dietary department, proper sanitation of the kitchen, proper food storage, any areas of concern or opportunities for improvement identified by the Registered Dietitian and/or State Surveyors. When DSS 2 was onsite and began in-servicing the Food and Nutrition Services staff, the IJ was removed on 12/17/23, at 1:06 p.m. while the surveyors were onsite. Findings: A. There was no full-time, competent oversight of the Food and Nutrition Services Department: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Review of the Dietary Supervisor Job Description dated 1/1/15, showed the duties and responsibilities of a Dietary Supervisor for Food and Nutrition Services, included but not limited to: inspecting storage areas and the dietary department regularly for proper temperature and cleanliness; providing in-service educational programs for the Dietary Department; and ensuring compliance with Federal regulations. Review of the Consultant Dietitian Nutritionist Job Description dated 2023, showed the Consultant Dietitian Nutritionist (RDN) provided oversight of the operations of the Department of Food and Nutrition Services. The responsibilities included but were not limited to: evaluating and participating in implementing in-service programs for the Department of Food and Nutrition Services; monitoring and recommending food service standards for sanitation, safety, and infection control; advising and counseling the dietary supervisor in all areas of food service; evaluating and monitoring the food service department to assure the department is providing adequate, acceptable quality food; reporting to the Administrator and the dietary supervisor, monthly or as needed regarding findings and concerns regarding the Department of Food and Nutrition Services. Review of the Agreement to Provide Consultant Services signed by ADM on 7/19/21, showed the purpose of the RDN consultant was to provide guidance and council to the Nutrition Services Department. The responsibilities of the consultant included but were not limited to offering in-service education to facility staff and reviewing sanitation in accordance with current regulatory standards. The contract showed hours as PRN [as needed] as negotiated with [the consulting company] and administrator. The number of hours shall be determined by the needs of the facility. Hours will be based on the average census, acuity rate of the facility and qualifications of the Director of Food and Nutrition Services. Review of the Cook Job Description dated 11/10, showed the basic purpose of the position was to prepare and serve food to residents of the facility in accordance with current Federal regulations, corporate standard regulations and guidelines, and may be directed by the Administrator or Dietary manager. The job description stated every effort has been made to identify the essential duties and responsibilities of this position. However, the functions listed below should not be considered a complete list of duties the position may be required to perform. The omission of specific statements of duties does not exclude them from the position of the work is similar, related, or is an essential function of the position. Duties and responsibilities listed included but were not limited to: ensuring all dietary procedures and sanitary regulations were followed in accordance with established policies; performing dishwashing/cleaning procedures; ensuring the department was maintained in a clean and safe manner by assuring that necessary equipment and supplies were maintained; cleaning work station and all equipment utilized, following each meal to maintain sanitary conditions; and assisting in maintaining food storage areas in a clean and properly arranged manner at all times. Review of the Dietary Aide Job Description showed the primary purpose of the position was to provide assistance in all dietary functions as directed/instructed and in accordance with established dietary policies and procedures. The job description read every effort has been made to identify the essential duties and responsibilities of this position. However, the functions listed below should not be considered a complete list of duties the position may be required to perform. The omission of specific statements of duties does not exclude them from the position of the work is similar, related, or is an essential function of the position. Duties and responsibilities listed included but were not limited to: cleaning workstation and all equipment utilized following each meal; cleaning worktables; performing dishwashing/cleaning procedures; and assist in maintaining food storage areas in a clean and properly arranged manner at all times. Review of the Policy titled Performance Reviews revised 5/1/22, showed each employee shall receive a review of their job performance at least annually. The performance review shall include an assessment of the employee's performance based on the stated job description, identified objectives, and professional standards for the individual and the facility as necessary and appropriate. The guidelines showed each employee shall be scheduled for a performance review during the month of the anniversary of that employee's seniority date with the facility. The performance review shall be completed by the employee's direct supervisor or the head of the department within which the employee spends the majority of their hours worked. Each performance review shall include an assessment of performance based on the job description and/or standards of practice for the employee's position, evaluation of performance against previously established goals, and a developmental action (as necessary and appropriate). On 2/13/23 at 8:55 a.m., during the initial tour of the kitchen, an observation, and concurrent interviews with Diet Aide 3 (DA 3) and [NAME] 1, showed DA 3 and [NAME] 1 working in the kitchen and a kitchen supervisor was not present. DA 3 washed dishes using the dish machine and stated she worked at the facility for two months, mornings and afternoons. [NAME] 1 stated he worked at the facility for six months and stated there was no kitchen supervisor during the week. He stated, he thought a new supervisor was hired but did not know when the new supervisor was going to start. On 2/13/23 at 9:35 a.m., an observation and interview with the Dietary Services Supervisor 1 (DSS 1), showed DSS 1 arrived in the kitchen and stated she was the new supervisor. In an interview on 2/13/23 at 12:23 p.m., DSS 1 stated she worked at another facility and was just at this facility to help during the survey. In an interview on 2/13/23 at 12:33 p.m., the Administrator (ADM) stated there was a Registered Dietitian who worked for the facility one day a week for 8 hours. ADM also stated a dietary supervisor (DSS 1) was just hired and she was coming into the facility three to four hours in the afternoons to get used to the kitchen. ADM confirmed currently there was no full-time supervisor for the kitchen. Review of the Employment Offer Letter signed by DSS 1 on 2/2/23, read Employee will begin as an hourly employee due to continuous arrangements of departure from previous employer. She will begin her employment as on on call hourly employee and will coordinate hours with administrator. Once she has departed from her previous employer, she will begin her full time salaried exempt position as Dietary Manager. Review of the Employee Timesheet for the DSS 1 dated 2/1/23 - 2/15/23, showed DSS 1 worked at the facility on 2/7/23 from 1:03 p.m., to 4:34 p.m. for a total of 3 hours and 31 minutes; 2/8/23 from 3:50 p.m. to 6:14 p.m. for a total of 2 hours and 24 minutes; 2/9/23 from 2:21 p.m. to 6:04 p.m. for a total of 3 hours and 43 minutes. These times showed a week total of 9 hours and 38 minutes. For the consecutive week (the week of the survey start date on 2/13/23), the time sheet showed DSS worked on 2/13/23 from 9:32 a.m. to 6 p.m. for a total of 8 hours and 28 minutes; 2/14/23 a start time was not shown and worked until 4:09 p.m. In an interview on 2/14/22 at 8:55 a.m., Diet Aide 1 (DA 1) stated Kitchen Staff 2 (KS 2) use to be a supervisor and now came in on the weekends to order food and do the food inventory. In an interview on 02/15/23 9:04 a.m. ADM stated Kitchen Staff 1 (KS 1) was the last full-time supervisor and had to check to find out the last date KS1 worked at the facility. ADM stated it was her understanding that DSS 1 was to be full-time eventually but right now she was transitioning part-time. The surveyor informed ADM that DSS 1 stated she was only going to work at the facility until the end of the survey. Review of an email from KS 1 to ADM dated 9/20/22, showed a KS 1 gave her formal notice of resignation on 9/20/22 making her last day of employment 10/3/22 (2 weeks from the formal resignation date). Review of the document titled All Timesheets for dates from 1/1/22 to 12/31/22, showed the last time sheet for KS 1 was from 10/1/22 to 10/15/22. In an interview on 2/15/23 at 11 a.m., Registered Dietitian 2 (RD 2) arrived at the facility and stated he worked for the same consulting company as Registered Dietitian 1 (RD 1). He stated he worked at this facility in the past and was like a supervisor for RD 1. He said if the surveyors had questions about the kitchen, the kitchen staff had to be asked, not RD 1. On 02/15/23 1:36 p.m., a phone interview was conducted with RD 1 in the presence of ADM. RD 1 stated she worked at the facility eight hours a week and she went into the kitchen for maybe one hour a month to complete a report of any concerns which she provided to ADM and the Director of Nursing (DON). RD 1 repeated she went into the kitchen once a month for about an hour said she did not go into the kitchen at any other time. RD 1 also stated she did not provide in-services to kitchen staff. On 2/15/23 3:30 p.m., DSS 1 stated she just came into the facility in the p.m. (afternoon/evening) She said she did not meet the a.m. (morning) staff until the survey began on Monday (2/13/23) because she was only at the facility helping in the p.m. In a phone interview with the DSS 1 on 2/16/23 at 8:09 a.m., DSS 1 stated she did not provide any documented in-services for kitchen staff. In an interview with ADM on 2/16/23 at 8:47 a.m., ADM stated she was aware that DSS would no longer work at the facility, and she did not know who was going to supervise the kitchen on Friday (2/17/23) this week or thereafter. On 02/16/23 at 12:46 p.m., ADM stated there were no records for competency evaluations done for any of the kitchen staff including [NAME] 1, [NAME] 2, Dietary Aide 1 (DA 1), Dietary Aide 2 (DA 2), and Dietary Aide 3 (DA 3). On 2/17/23 at 1:15 p.m., ADM stated there was not a supervisor to supervise kitchen staff during day-to-day operation since KS 1 left. She stated Kitchen Supervisor 2 (KS 2) was also a past supervisor and now came into the kitchen on the weekends mainly for the task of ordering food. She stated recruitment for a kitchen supervisor was advertised on one online recruiting site, and she had only one qualified candidate from the site during the time the job was posted. ADM provided documentation printed from the one recruiting website which showed Dietary Manager was posted on September 20, 2022, and on December 8, 2022. ADM said the facility did not hire the only qualified candidate for the Dietary Manager position through the recruiting site because the facility decided to hire DSS 1. ADM stated the Regional Administrator (RADM) researched a company to contract with for nutritional services, who would provide staffing, but the facility decided not to contract with them. She said she did not remember if she contacted any consulting agencies to recruit a kitchen supervisor. On 2/17/23 at 2:02 p.m., ADM stated the facility did not contact any consulting companies or recruit in any other way other than advertising for the kitchen supervisor position on the one internet site. B. There was no full-time, competent supervision of the Food and Nutrition Department to ensure safe food storage: According to the 2022 Federal Food Code, the person in charge is to ensure that employees are properly maintaining the temperature of time/temperature control for safety foods during cold holding and thawing through daily oversight of the employees' routine monitoring of food temperatures. Time/Temperature Control for Safety (TCS) Food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism (an organism which can cause disease) growth or toxin (a naturally occurring organic poison) formation. Examples of TCS foods include animal food that is raw or heat-treated, cut melons, cut leafy greens). Except during preparation, cooking, cooling or when time is used as the public health control, TCS food is to be held at 41 degrees F or less. Also, when TCS foods are thawed using refrigeration, the food temperature is to be maintained at 41 degrees Fahrenheit (F) or less. In addition, in the Food Code Annex, it is stated that after being cut, certain produce such as melons and leafy greens should be stored at 41 degrees or below to prevent any pathogens that may be present from multiplying. Also, freezing prevents microbial growth (increased number of bacterial [bacteria is a large group of single-cell microorganisms. Some cause infections and disease in animals and humans] growth) in foods, but usually does not destroy all microorganisms (microscopic [cannot be seen by the human eye but can be seen under a microscope] organisms, especially a bacterium, virus, or fungus). Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins (a naturally occurring poison produced by organisms). In the Food Code Annex, it is also said that Epidemiological (the branch of medicine which deals with finding the cause of diseases) outbreak (a sudden start of a disease in a community or geographical area) data repeatedly identify improper holding temperatures as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness. Review of the policy and procedure titled Sanitation and Infection Control Subject: Refrigerated Storage dated 2023, showed refrigerator temperatures should be recorded two times each day. It is recommended temperatures be recorded in the a.m. (morning) immediately after opening the kitchen and the p.m. (evening) before closing. Perishable foods should be stored less than or equal to 41 degrees F (Fahrenheit). Review of the policy and procedure titled Food Preparation Subject: Food Defrosting Methods dated 2023, showed food will be thawed in a manner as to keep food out of the danger zone (41 - 140 degrees F) for the entire thawing process. When defrosting in the refrigerator, foods must be labeled and dated with the item name, pull dates and use-by date with no more than three days past the pull-by date. On 2/13/23 at 8:55 a.m., during the initial tour of the kitchen, an observation and concurrent interviews with Diet Aide 3 (DA 3) and [NAME] 1, showed 2 staff (DA 3 and [NAME] 1) were working in the kitchen and a kitchen supervisor was not present. [NAME] 1 stated he worked at the facility for 6 months and stated there was no kitchen supervisor. He stated, he thought a new supervisor was hired but did not know when the new supervisor was going to start. As the initial tour of the kitchen continued on 2/13/23 at 9 a.m., and observation and concurrent interview with [NAME] 1 showed a 3-door reach-in refrigerator filled with food. An internal thermometer showed the refrigerator was 50 degrees Fahrenheit (F). The surveyors asked [NAME] 1 if there was documentation for refrigerator temperatures. [NAME] 1 showed the surveyors a clipboard hanging on the wall next to the refrigerator. He showed that the last documented temperatures for the refrigerator were from November 2022. Then he looked through a binder and found documented refrigerator temperatures documented for 1/25/23. [NAME] 1 was not able to find any refrigerator temperature documentation for February. Review of the document titled Food Temperature/Sanitation Record dated 1/25/23 showed two documented refrigerator temperatures documented at 5:30. As the initial tour continued on 2/13/23 at 10 a.m., the three-door, reach-in refrigerator was observed in the presence of DSS 1, DA 3, and [NAME] 1 (DSS 1, DA3, and [NAME] 1 were also interviewed at this time). The thermometer inside the refrigerator showed 46 degrees F. Food temperatures were measured with calibrated surveyor thermometers. A nutrition supplement shake taken from a box holding multiple shakes and dated 2/7 had a temperature of 48.6 degrees F. DA 3 stated he thought the shakes had been in the refrigerator and not removed from refrigeration for 5 days. A yogurt in an individual container was 43.9 degrees F. Sour cream from an opened container was 43.5 degrees F. DSS 1 confirmed the temperatures taken. She said the temperature of food stored in the refrigerator should be 34 degrees or lower. Other items in the refrigerator included thawing raw chicken in a metal container with a label which showed it was placed in the refrigerator on 2/11 and was to be used by 2/16 and 2 packages of raw thawing pork with a label that showed it was placed in the refrigerator on 2/12 and was to be used by 2/16. The chicken appeared soft and fully thawed and the pork was soft to the touch and felt fully thawed, and there were red juices inside the metal container holding the thawing pork. [NAME] 1 stated the raw chicken in the refrigerator was leftover and he might cook it tomorrow. The temperature of the chicken stored in the refrigerator measured 44.6 degrees F. DSS 1 stated thawing meat should only be held for 3 days. In an interview on 2/13/23 at 2:55 p.m., the DSS 1 stated after reviewing refrigerator temperature logs, the last documentation available was on 1/25/23. On 2/14/23 at 8:22 a.m., an observations and concurrent interviews with Diet Aide 1 (DA 1) and [NAME] 2, showed DA 1 and [NAME] 2 working in the kitchen without a supervisor. The 3-door refrigerator temperature was checked. The thermometer read 42 degrees F. [NAME] 2 and DA 1 stated they did not check the refrigerator temperature today. The Record of Refrigeration Temperatures dated February 2023 was blank in the space designated to record a temperature on 2/13/23. Temperatures of food stored in the refrigerator were measured with surveyor calibrated thermometers. Tuna salad dated 2/10/23 was 46.2 degrees F. Cut cantaloupe dated 2/11 - 2/16 was 44.8 degrees F. An undated package of raw, thawed pork was 48 degrees F and 46.8 degrees F (the temperature was measured in two places inside the pork), shredded cabbage stored in an opened plastic bag labeled prep [preparation] date 2/10/23 Use by 2/16/23 was 46.2 degrees F, shredded mozzarella cheese in an opened plastic bag labeled prep 2/8/23 use by 3/8/23 was 44.4 degrees F, shredded cheddar cheese in an opened plastic bag labeled prep date 2/9/23 use by 3/9/23 was 46 degrees F, an opened container of Caesar salad dressing was 45 degrees F, a nutrition supplement shake in a cardboard box dated February 7 and containing multiple shakes all dated use by Feb [February] 18 was 48.4 degrees F. DA 1 and [NAME] 2 both stated all the food measured for temperature were stored in the refrigerator overnight and not removed from refrigeration that morning. In an interview and observation with DSS 1 and [NAME] 2 on 2/14/23 at 11:20 a.m., showed DSS 1 arrived at the facility to begin work. The surveyor informed the DSS 1 of the food temperatures found in the refrigerator at 8:22 a.m. The DSS 1 stated okay. [NAME] 2 stated he documented the refrigerator temperature at 11:10 a.m. He said the refrigerator temperature should not be above 42 degrees F and 45 degrees F was okay because the refrigerator temperature can go up when the door was opened and closed many times. DSS 1 informed [NAME] 2 the refrigerator temperature had to be 41 degrees or below. Review of the document titled Record of Refrigeration Temperatures dated February 2023, showed 45 degrees documented for the refrigerator on 2/14/23. Directions typed at the bottom of the documented showed Refrigeration: Not greater than 41 degrees F . Report to Supervisor when recorded temperatures are not adequate. On 2/14/23 at 1:30 p.m., an observation and concurrent interview with the DSS 1 showed two thermometers on inside the 3-door reach-in refrigerator with temperatures measuring 42 degrees F and 45 degrees F. The DSS 1 stated new thermometers were needed and the food inside the refrigerator was okay. On 2/14/23 at 1:47 p.m., an observation and interview with the DSS 1 and DA 1, showed the same foods stored in the 3-door reach-in refrigerator that were observed in the morning (on 2/14/23 at 8:22 a.m.). The temperature of the food was measured with the surveyors' calibrated thermometers in the presence of DSS 1. Two temperatures were taken of the raw, thawed pork and were 48.7 degrees F and 46.8 degrees F. The cut cantaloupe was 45.5 degrees F, shredded cabbage in an opened plastic bag dated 2/10/23 - 2/16/23 was 46.8 degrees F, the opened bag of shredded cheddar cheese dated 2/9/23 - 3/9/23 was 47.5 degrees F, opened bag of shredded mozzarella cheese 46.9 degrees F, a nutrition supplement shake from the cardboard box dated 2/7 was 48.2 degrees F, the opened container of Caesar dressing was 48.2 degrees F. DA 1 stated all the food that was measured for temperatures were not removed from refrigeration that day. DSS 1 stated the foods with high temperatures needed to be discarded. The surveyor asked if other food stored in the refrigerator was safe, she stated she needed to speak with RD 1. In an interview on 2/14/23 at 2:04 p.m., DSS1 stated RD 1 said to discard all the food in the refrigerator. She also stated maintenance had to adjust the temperature of the refrigerator. On 02/15/23 at 10:13 a.m., an observation, interview, and review of the refrigerator temperature log with [NAME] 2 and DA 1, showed the log titled Record of Refrigerator Temperatures revised 4/11/16, had a total of 3 documented temperatures on the log for February 23 which included one documented temperature on 2/13/23, 2/14/23, and 2/15/23. [NAME] 2 stated there were no temperatures documented by an afternoon staff, but there should be. He stated an afternoon temperature should be documented as well as the morning temperature. Food items which were observed in the refrigerator on 2/14/23 continued to be stored in the refrigerator and not discarded. These items included a bag of mixed green lettuce labelled opened 2/11/23, the opened container of Caesar dressing, the opened bag of shredded cabbage labeled prep date 2/10/23 Use By Date 2/16/23, the opened bag of shredded mozzarella cheese labeled Prep Date 2/8/23 Use By 3/8/23, the opened bag of cheddar cheese. In an interview on 2/15/23 at 12:15 p.m., [NAME] 2 stated he planned to use the opened bag of shredded cabbage labeled prep date 2/10/23 Use by 2/16 for the pepper slaw on the menu for lunch on 2/16/22. Review of the Daily Spreadsheet dated Wednesday - Day 4 showed mixed pepper slaw on the menu for dinner. In an interview on 2/15/23 at 12:20 p.m., ADM stated the refrigerator was fixed about 8:30 p.m. on 2/14/23. She said she did not know if the refrigerator temperatures were checked again to make sure the refrigerator was working. On 2/15/23 at 1:36 p.m., RD 1 was interviewed over the phone in the presence of ADM. RD 1 stated she thought there was a log for refrigerator temperatures and that the kitchen staff were responsible for checking refrigerator temperatures. She stated she thought refrigerator temperatures had to be checked at least once or twice a day. She said if the refrigerator temperatures were high then maintenance should be informed. RD 1 also stated the temperature of the food should be taken and to discard the food if the temperature was high. She said she did not know if kitchen staff knew the correct procedures to follow if refrigerator temperatures were high. RD 1 said she did not provide any in-services to the kitchen staff. She stated she did tell the staff to discard the food in the refrigerator on 2/14/3, but she did not know if the food was discarded. She said the reason the food had to be discarded was because the food temperature was high and was in the potentially hazardous zone. An observation on 2/15/23 at 3 p.m., the DSS 1 arrived at the facility. In an interview on 12/15/23 at 3:30 p.m., DSS 1 stated yesterday (2/14/23), she left about 5:30 p.m. She stated all food was supposed to be discarded from the refrigerator except for unopened shelf stable food (food that does not require refrigeration). She said shredded cabbage, cheese, and lettuce was supposed to be discarded. On 2/16/23 at 11:55 a.m., an observation and interview with the Director of Nursing (DON), the DON showed the surveyor a binder containing documented in-services provided to kitchen staff. She said these were the only in-services she could find having to do with the kitchen. The documents showed all the in-services were dated 2022 and did not show who conducted the trainings. There was no in-service available to show any kitchen staff, including [NAME] 1, [NAME] 2, DA 1, DA 2, and DA 3, were trained regarding monitoring refrigerator temperatures and safe food storage temperatures. In an interview with DA 1 and [NAME] 1 on 2/16/23 at 2 p.m., DA 1 stated she never received training from an RD, including the current RD 1. DA 1 stated when RD 1 came into the kitchen, RD 1 looked at things, filled out her report, and then left the kitchen. [NAME] 1 also stated he did not receive training from an RD. He stated he just started looking at refrigerator temperatures in the evening. He said the refrigerator temperature should be 32 to 35 degrees F and stated 45 degrees F was okay because the temperature could go up when the refrigerator door was opened. He stated he would only take action if the refrigerator temperature was 50 degrees F because 50 degrees was too high. He stated he did not document the temperature when he checked it. C. There was no full-time, competent oversight to ensure proper use of the dish machine: According to the 2022 Federal Food Code, the person in charge is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of chemical concentration and temperature for chemical sanitizing. In addition, a warewashing machine and its auxiliary components are to be operated in accordance with the machine's data plate and other manufacturer's instructions. A test kit or other device that accurately measures the concentration of sanitizing solution is to be provided. In the Food Code Annex, it is said to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. In addition, the Food Code Annex explains Epidemiological outbreak data repeatedly identify contaminated equipment as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness. Review of the policy and procedure titled Sanitation and Infection Control Subject: Dishwashing Procedures (Dish machine) dated 2023, showed the dish machine will be used per manufacture guidelines. Chemical low temperature dish machines must maintain a water temperature of 120 degrees F - 140 degrees F. Use a chemical sanitizing rinse to achieve and maintain 50 - 100 ppm (parts per million) of chlorine at the dish surface or according to manufacturer's specifications. Obtain test' strips form your local chemical distributor for testing ppm on low temperature machines. Dish machine temperature logs must be documented prior to the start of washing at each meal to ensure proper sanitation of all dishware and trays. If temperatures are out of standards, circle and record action plans on form.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the required room size of at least 80 square feet per resident for one of 23 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. Findings: During an interview on 2/13/23, at 8:20 a.m., with the Administrator (ADM), ADM stated, room [ROOM NUMBER] had less than 80 sq ft per resident and had four resident beds. ADM also stated, there was no room waiver for room [ROOM NUMBER]. During a concurrent observation and interview on 2/14/23, at 12:35 p.m., room [ROOM NUMBER] had four resident beds. The privacy of residents in room [ROOM NUMBER] were not impacted by shortage of space. Storage spaces were sufficient to accommodate the needs of residents. Resident 7 was sitting up in her wheelchair watching television. Resident 7 stated, she had no issues with maneuvering her wheelchair inside room [ROOM NUMBER]. Resident 8B indicated, she had no issues with room space nor had complaints with privacy during care. There was no negative outcome in the delivery of nursing care and services. The ADM requested a continuous room waiver for the above residents' room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on observation, and interview the facility failed to maintain working clocks for 10 of 10 sampled residents (Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36) in their rooms. This failure placed Resident 1, 2, 7, 8B, 12, 16, 22, 23, 26 and 36 at risk for confusion and disorientation. Findings. During an observation and interview on 02/14/23, at 10:24 a.m., with Licensed Vocational Nurse (LVN 3), the wall clock in shared room for Resident 23 and Resident 26, indicated the time was 6:20. During an observation and interview on 2/14/23, at 10:29 a.m., in Resident 12 and 22's shared room, LVN 3 stated, the wall clock indicated time was 2:48. During an observation and interview on 2/14/23, at 10:31 a.m., with LVN 3, wall clock in Resident 36's room showed time was 11:45; and the wall clock in Resident 2 and 16's room indicated time was 11:30. During another observation and interview on 2/14/23, at 10:32 a.m., in shared room for Resident 1,7 and 8B, LVN 3 stated, wall clock indicated time was 5:15. During an interview on 2/14/23, at 10:33 a.m., LVN 3 stated, Resident 23, 26, 12, 22, 36, 1, 7 and 8B were mostly disoriented. LVN 3 stated, a working clock displaying correct time was important for all residents so that they know the time, and it's worse for them if they have dementia (memory loss). LVN 3 further stated, as the primary nurse, she was responsible to ensure wall clocks were working. LVN 3 stated, she had noticed the clocks being off before and was busy to get them fixed. During an interview on 02/14/23, at 10:38 a.m., with Director of Nursing (DON), DON stated, having a broken clock could impact resident's orientation to time and make them confused. The DON stated, working clocks in the resident rooms were important for the staff to orient the residents to place, time, and day.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide an easily accessible bathroom to three of three sampled residents (Resident 5, 32 and 29). Resident 5 and 32 shared a bathroom with two female residents, that they could not use. Resident 29 did not have a bathroom in the room. This failure resulted in Resident 5, Resident 32 and Resident 29 to not have a homelike environment, having to wait for extended periods of time to use the bathroom, and an increased number of incontinent (unable to voluntarily control their bladder and/or bowels) episodes. Findings: 1. During an observation on 2/14/23, at 8:08 a.m., in Resident 32 and 5's shared room, a sign was posted on the bathroom door indicating, BATHROOM CLOSED USE HALLWAY BATHROOM. During an interview with Resdent 32 on 2/14/23 at 8:08 a.m., Resident 32 stated, Resident 5 and himself shared the bathroom with two female residents (Resident 19 and 33) residing in the adjacent room. Resident 32 stated, he used the hallway bathroom and it bothered him. Resident 32 further stated, he was trying to give the ladies their privacy. Resident 32 also stated, it would have been nice to have their own bathroom in the room; and not share with the female residents. During a review of Resident 32's Resident Face Sheet dated, 2/15/23 indicated, Resident 32 was admitted to the facility on [DATE]. During a review of Resident 32's MDS dated [DATE], the assessment indicated, Resident 32 was frequently incontinent (unable to voluntarily control their bladder and/or bowels) and had a BIMS score of 12 out of 15, indicating intact mental status with confusion at times. The MDS assessment also indicated, Resident 32 required one staff's extensive assistance when toileting. 2. During a review of Resident 5's Resident Face Sheet dated 2/15/23, the face sheet indicated, Resident 5 was admitted to the facility on [DATE]. During a review of Resident 5's Minimum Data Set (MDS- an assessment tool to guide care) dated 12/14/22, the MDS assessment showed Resident 5 was always continent (able to voluntarily control bladder and/or bowels) and had a BIMS (Brief Interview for Mental Status- a tool used to assess mental status of resident) score of 13 out of 15, indicating intact mental status. The MDS assessment also showed Resident 5 required one staff's limited assistance when toileting. During an interview with a Certified Nursing Assistant (CNA1) on 2/15/23, at 9:13a.m., CNA1 stated, Resident 32 required assistance using the bathroom, was frequently incontinent and used adult briefs. CNA1 stated, Resident 32 used the bathroom in the far hallway (BR 2, about 76 feet from Resident 32's room) that's on the other side of building when the closest hallway bathroom (BR 1, about 19 feet away from Resident 32's room) was in use. CNA1 stated, Resident 32 at times had incontinent episodes because the hallway bathroom was too far away from his room. During a concurrent interview and record review with the Director of Nursing (DON), on 2/15/23, at 11:12 a.m., facility's document titled Resident's [NAME] of Rights, Environment dated 5/1/22 was reviewed. The DON stated, facility used above mentioned document as a guide for accommodation of needs. The DON stated, the document indicated, You have the right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatments and supports for daily living safety. 3. During a record review of Resident Face Sheet for Resident 29 dated 02/15/2023, the record indicated Resident 29 was admitted to the facility in 2020. During a review of Resident 29's MDS assessment dated [DATE], Section C showed a BIMS (an assessment tool used to evaluate mental status) score of 15 out of 15, indicating intact mental status. Section H showed Resident 29 was continent (had control) of bowel and bladder. Section G showed Resident 29 required staff's supervision or oversight for toileting, transferring on or off the toilet, and cleaning self after elimination. During an observation and interview on 02/13/23, 08:57 a.m., in Resident 29's room, Resident 29 stated, he did not have a bathroom attached to his room. Resident 29 stated, facility had only two community bathrooms. Resident 29 stated, it was hard for him to use the community bathroom when bathroom got busy after lunch and there was a line of residents to use the bathroom at the same time. Resident 29 stated, it was hard specially when he needed the bathroom for bowel movement. During an interview with Resident 29 on 02/13/23, at 11:49 a.m., Resident 29 stated, not having a bathroom in his room and having to wait to use the bathroom made him feel like he wasn't at home. Resident 29 stated, he used his urinal if the community bathroom was busy. Resident 29 also stated, he often had to empty his own urinal when staff do not answer his call light. During an observation and interview with CNA 2 on 02/15/23, at 12:20 p.m., facility community bathrooms were observed. First Bathroom (BR 1) was next to the dining area and was 24 feet away from Resident 29's bed. Second bathroom (BR 2) was by nursing station 1, which was 81 feet away from Resident 29. CNA 2 stated, Resident 3, 5, 32, and Resident 29 all try to use the BR 1 after lunch. CNA 2 stated, neither bathroom had a lock, but BR1 had a curtain that provided privacy to the toilet area so Residents were not seen if someone walked in. BR2 had the toilet situated immediately to the left when entering the bathroom and there was no privacy curtain so anyone entering the bathroom could see the person using the toilet. CNA 2 stated, he has walked in on the residents in the past while they were on the toilet.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to complete a performance review for four of five CNA's (Certified Nurse Assistant) at least once every 12 months. This failure had the potential to result in inadequate care and services provided to residents. Findings: During a concurrent interview and record review, on 2/15/23, at 1:00 p.m., with the Director Of Nursing (DON), a review of the following CNA record indicated: a. CNA 4 was hired on 4/15/85, no performance review on file for 2022. b. CNA 5 was hired on 6/16/09, no performance review on file for2022. c. CNA 3 was hired on 4/15/10, last performance review on file was 12/20/21. d. CNA 6 was hired on 7/29/17, last performance review on file was 11/2019. The Director of nursing (DON) stated, she was the previous Director of Staff Development (DSD) until January 2023. DON stated, she did not perform performance review for the unlicensed nurses in 2022 because she did not have time to do it. DON further added, resident safety is at risk when performance review of direct care staff was not done. During a review of the facility's policy and procedure (P&P), titled Performance Reviews, dated 11/1/22, the P&P indicated, under policy Each employee shall receive a review of their job performance at least annually .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to administer medications below five percent (5%) error rate when: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine( drug used for relief of nasal and non-nasal symptoms of seasonal allergies) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan 0.1% and Dorzolamide-timolol 2-0.5%, to Resident 34. 3. LVN 3 documented she gave Metformin (a medication used for diabetes) 500 mg to Resident 8B, but did not give the medication as prescribed. These significant medication errors resulted in Residents 29, 34 and 8B receiving medications that were not prescribed by their physicians. Findings: 1. During a medication administration observation on 2/14/23, at 8:44 a.m., Licensed Vocational Nurse 2 (LVN 2) prepared the following seven medications for Resident 29: Loratadine was not included in the seven medications. During a concurrent interview and review on 2/14/23 at 1:23 p.m., with LVN2, Resident 29's medication administration history dated 2/14/23, reviewed. LVN 2 stated, the record indicated she administered one tablet of Loratadine 10 mg at 9:08 a.m. LVN 2 further stated, she didn't really give Loratadine to Resident 29 at 9:08 am because she did not have the medication in the medication cart. 2. During a medication pass observation on 2/14/23, at 9:19 a.m., LVN 2 was observed preparing five medications for Resident 34: - Lorazepam (used to treat several conditions including agitation) 0.5 mg tablet as needed for dementia agitation - Eliquis (used to reduce blood clotting by thinning the blood) 2.5 mg tablet - Furosemide (used to treat fluid buildup) 20 mg tablet - Metoprolol ER [extended release] 25 mg tablet - multivitamin w/mineral LVN 2 crushed all the meds, placed them in a small cup and poured approximately 100 ounces of juice into a cup. LVN mixed the crushed medications with applesauce. LVN 2 administered the medication mixture to Resident 34. During a concurrent interview and review of metoprolol medication label instructions with LVN 2 on 2/14/23, at 9:26 a.m., LVN 2 stated, the medication label indicated Do not chew or crush. During a concurrent interview and review on 2/14/23, at 9:37 a.m., with LVN 2, Resident 34's physician orders for 2/2023 were reviewed. LVN 2 stated, facility did not have a physician order to crush Resident 34's medications. LVN 2 also stated, extended-release medications should not be crushed because it could cause a much faster release of medication in Resident 34's body and cause a quick drop in her blood pressure. During a concurrent interview and review on 2/14/23, at 12:05 p.m., with LVN 2, Resident 34's medication administration history dated 2/14/23 reviewed. LVN 2 stated, the record indicated, she administered one drop of Alphagan P drops 0.1% (used for glaucoma) to left eye, and 1 drop of Dorzolamide-timolol drops 2-0.5% (used to lower pressure in the eye to prevent blindness) to left eye to Resident 34 at 9:19 a.m. Observed during medpass LVN 2 did not administer eye drops at that time. 3. During a medication administration observation on 2/14/23, at 10:00 a.m., Licensed Vocational Nurse 3 (LVN 3) prepared and administered the following seven medications to Resident 8B. Metformin was not included in the administered seven medications. During a review of the facility's policy and procedure titled Medication Administration General Guidelines dated September 2018, subsection titled Medication Administration stated medications are administered in accordance with written orders of the prescribers. The policy also stated, medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The subsection titled Documentation stated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given . If dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer medications per physician order or manufacturer's specifications to three of seven sampled residents when the following was noted: 1. Licensed Vocational Nurse (LVN 2) did not administer Loratadine (drug used for relief of nasal and non-nasal symptoms of seasonal allergies. ) 10 mg medication to Resident 29. 2. LVN 2 crushed Metoprolol (a medication used to lower the blood pressure) Extended Release (a medication released slowly in the bloodstream) 25 milligrams (mg) tablet without a physician's order. LVN 2 did not administer two eye drops, Alphagan (eye drops for glaucoma) 0.1% and Dorzolamide-timolol(eye drops for glaucoma and intraocular/eye pressure) 2-0.5%, to Resident 34. 3. LVN 3 documented Metformin (a medication used for diabetes) 500 mg as given to Resident 8B, but did not give at the documented time. These significant medication errors resulted in Residents 29, 34 and 8B not receiving medications as ordered by their physician. Findings: 1. During a medication administration observation on 2/14/23, at 8:44 a.m., Licensed Vocational Nurse 2 (LVN 2) prepared the following seven medications for Resident 29: - polyethylene glycol 3350 (a medication to treat constipation) 17 grams/dose (grams, a unit of measure) mixed with approximately 100 ounces (double check this volume) of juice - aspirin 81 milligrams (mg, a unit of measure) chewable, 1 tablet - dipyridamole (inhibits blood clot formation) 75 mg tablet, 1 tablet - gabapentin (used to treat seizures or nerve pain) 300 mg capsule, 1 capsule - Lasix (used to treat fluid build up) 20 mg tablet, 1 tablet - metoprolol ER (used to treat high blood pressure) 25 mg tablet, 1 tablet - Vitamin D 2000 IU, 1 capsule LVN 2 placed the medications in a tray and brought them to Resident 29. LVN 2 identified each medication and Resident 29 placed them on a tissue. Resident 29 took the medications individually with water and drank the polyethylene glycol mixture. During a concurrent interview and review on 2/14/23 at 1:23 p.m., with LVN2, Resident 29's medication administration history dated 2/14/23 was reviewed. LVN 2 stated the record indicated she administered one tablet of Loratadine 10 mg at 9:08 a.m. LVN 2 stated, she didn't give Loratadine to Resident 29 at 9:08 am because she did not have the medication in the medication cart. LVN 2 also stated she did not even realize that she missed to give the medication until 11:00 am that day. 2. During a medication pass observation on 2/14/23, at 9:19 a.m., LVN 2 was observed preparing five medications for Resident 34: - Lorazepam ( scheduled medication and high potential for abuse) used to treat several conditions including agitation) 0.5 mg tablet as needed for dementia agitation - Eliquis (used to reduce blood clotting by thinning the blood) 2.5 mg tablet - Furosemide (used to treat fluid buildup) 20 mg tablet - Metoprolol ER [extended release] 25 mg tablet - multivitamin w/mineral LVN 2 crushed all the meds, placed them in a small cup and poured approximately 100 ounces of juice into a cup. LVN raised the head of Resident 34's bed and mixed the crushed medications with applesauce. LVN 2 administered the medication mixture to Resident 34 and gave her the juice. During a concurrent interview and review of metoprolol medication label instructions with LVN 2 on 2/14/23, at 9:26 a.m., LVN 2 stated the medication label read Do not chew or crush. See drug reference: https://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/7262cesid=aWVSA81H4Z1&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dmethadone%26t%3Dname%26acs%3 During a concurrent interview and review on 2/14/23, at 9:37 a.m., with LVN 2, Resident 34's physician orders for 2/2023 were reviewed. LVN 2 stated facility did not have a physician order to crush Resident 34's medications. LVN 2 also stated extended-release medications should not be crushed because it could cause a much faster release of medication in Resident 34's body and cause a quick drop in her blood pressure. During an interview with Director of Nursing (DON) on 2/15/23, at 2:41 p.m., the DON stated, if medications were not crushable, the nurse should call the physician to get a comparable medication to crush or get an order to crush the medication. During a concurrent interview and review on 2/14/23, at 12:05 p.m., with LVN 2, Resident 34's medication administration history dated 2/14/23 was reviewed. LVN 2 stated, the record showed she administered one drop of Alphagan P drops 0.1% (used for glaucoma) to left eye, and 1 drop of Dorzolamide-timolol drops 2-0.5% (used to lower pressure in the eye to prevent blindness) to left eye to Resident 34 at 9:19 a.m., however she did not administer them at that time. 3. During a medication administration observation on 2/14/23, at 10:00 a.m., Licensed Vocational Nurse 3 (LVN 3) prepared and administered the following seven medications to Resident 8B: - diltiazem HCL ER (used to treat high blood pressure and certain irregular heartbeats) 180 mg capsule once a day - Vitamin C 500mg capsule, twice a day - clopidogrel (used to decrease blood clotting) 75 mg tablet, once a day - Symbicort HFA (used to treat chronic obstructive pulmonary disease - a lung disease that makes it hard to breathe) aerosol inhaler 160 mcg/4.5 mcg (mcg - a unit of measure) - multivitamin w/mineral, one tablet - gabapentin (used to treat seizures or nerve pain) 300 mg capsule twice a day - ferrous sulfate (used to treat iron deficiency) 325 mg tablet twice a day During a concurrent interview and review with LVN 3 on 2/14/23, at 2:05 p.m., Resident 8B's medication administration history dated 2/14/23 reviewed. LVN 3 stated, the record indicated she administered one tablet of Metformin 500 mg in addition to above mentioned seven medications at 10:00 am to Resident 8B. However LVN 3 stated, she administered Metformin at 7:30 am. During a concurrent interview on 2/15/23, at 2:44 p.m., the DON stated, nurses were expected to document the actual time of the medication administration, and not the time it was due for administration to the resident. The DON stated, acceptable medication administration times were one hour before and one hour after the due time. During a review of the facility's policy and procedure titled Medication Administration General Guidelines dated September 2018, subsection titled Medication Administration stated medications are administered in accordance with written orders of the prescribers. The policy also stated, medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The subsection titled Documentation stated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given . If dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record .

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility document review, the facility failed to ensure a cook was competent in the task of following a recipe to puree food. The failure had the potential to affect the nutrient content and or palatability of the food and result in decreased nutrient intake by nine residents on a physician prescribed pureed diet out of a facility census of 35. Findings: Review of the policy and procedure titled Food Preparation Subject: Portion Control dated 2023, showed portion control assures correct quantities are served to residents to meet the nutritional specifications as determined by the menu. Standard portions are necessary to control quality, attractiveness and appeal of food. Standard tools are utilized to assure portion control including recipes. Review of the Job Description titled Cook and signed by [NAME] 1 on 8/13/2017, showed duties and responsibilities included preparing food in accordance with standardized recipes. Review of the undated recipe tiled Pot Roast - 3 oz [ounce], showed directions on how to prepare the pot roast. Under the sections Diets, the recipe showed to refer to Pureed Meat - 3 oz recipe (# [number] P15) for the pureed diet. Review of the undated recipe titled Pureed Fish/Meat/Poultry - 3 oz and designated as Recipe #: P15, showed for five, three-ounce portions of pureed meat to use 15 ounces of cooked meat product and one cup of reserved cooking liquid or broth and 1.5 teaspoons of thickener. The directions showed to remove required portion amounts from the regular prepared recipe; place in the food processor. The directions showed that the portion of meat did not include juices or gravy. Then process the meat until a smooth consistency. Gradually add broth or gravy and thickener to the meat while processing. Notes in the recipe showed the volume of liquid required may be adjusted depending on the texture and moisture content of the product and the amount of thickener will vary slightly. Start with 1.5 teaspoons and add more gradually until the desired texture is achieved. An observation and interview with [NAME] 1 and DS on 4/24/23 at 10:50 a.m., showed [NAME] 1 prepared pureed food for nine residents on a pureed diet. [NAME] 1 added one small scoop of cooked pot roast into a blender. Then he added a ladle full of liquid from the cooked pot roast into the blender. Then he blended the meat and the liquid to a thin, pourable consistency. Then he added more liquid from the cooked pot roast and blended again. [NAME] 1 than added more cooked pot roast and seven pumps of liquid food thickener. He blended again and added seven additional pumps of liquid food thickener. [NAME] 1 confirmed he added a total of 14 pumps of food thickener to the pureed pot roast. DS stated [NAME] 1 should have blended the cooked meat first then added liquid as needed for the correct pureed consistency.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility document review, the facility failed to ensure pureed food was prepared in a consistency to meet resident needs. This failure placed eight (8) residents who received a pureed diet at risk for choking and/or aspirating (inhaling food into the lungs) out of a facility census of 34. Findings: Review of the Diet Manual Rehabilitation, Residential, and Long-Term Care Facilities dated 2018, foods for the pureed diet should be smooth and pureed to the consistency of pudding and holds its shape on a plate. Blendarized foods that are liquid may need to be thickened. Review of the Daily Spreadsheet dated Tuesday - Day 3 and used for lunch on 2/14/23, showed the Pureed food included Braised Pork Shoulder Puree, Pureed Sauteed Broccoli Florets, and Seasoned [NAME] Puree. Review of the undated recipe titled Braised Pork Shoulder showed for the pureed diet, to refer to the Pureed Meat recipe. Review of the undated recipe titled Sauteed Broccoli Florets (Fresh), for the puree diet, to refer to the Pureed Vegetables Recipe. On 2/14/23 at 11:34 a.m., [NAME] 2 prepared pureed food for the lunch meal. First, he pureed a fruit cobbler in a food processor. The final product was runny. [NAME] 2 poured the pureed fruit cobbler into individual bowls. Then [NAME] 2 used the food processor to puree rice. He added rice and water to the food processor. The product was runny. He poured the pureed rice into a metal container ready for the trayline food service. On 2/14/23 at 12:20 p.m., an observation of trayline food service showed the pureed pork, pureed rice, and the pureed broccoli was pourable and was served on a divided plate (a plate that is sectioned with built-up sides which keeps food separated) so the foods did not run together. In an interview on 2/15/23 at 4:56 p.m., DSS 1 stated pureed foods should not be runny, like it was for lunch on 2/14/23. She stated pureed food should hold its shape. On 2/16/23 at 8:58 a.m., [NAME] 2 stated there were no recipes for pureed meat or pureed vegetables. He also stated he did not have a seasoned rice recipe for the pureed diet. He said these recipes used to be available when the prior supervisor worked at the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and facility document review, the facility failed to ensure the planned menu was followed when: 1. Cake was not served to 10 of 10 Controlled Carbohydrate diets (CCHO; a diet to control the amount of carbohydrate or sugar a person receives at each meal); 2. A smaller portion of vegetables and potatoes than what was indicated on the menu were served to 9 of 9 residents on regular portion/regular textured diets; 3. A smaller portion of meat, a larger portion of vegetable, and a larger portion of cake than what was indicated on the menu were served to 7 of 7 residents on regular pureed diets; 4. A larger portion of meat and a larger portion of potatoes than what was indicated on the menu and traycard was served to Random Resident 1 (RR1) 5. A smaller portion of meat than what was indicated on the menu and traycard was served to Resident 6. This failure had the potential for residents to not receive the nutrients intended by the physician's order and the planned menu for 29 residents out of a facility census of 35. Findings: Review of the policy and procedure titled Food Preparation Subject: Portion Control dated 2023, showed portion control assures correct quantities are served to residents to meet the nutritional specifications as determined by the menu. Portions served ore those listed on the menu for each food item. Standard tools are utilized to assure portion control. Scoops sizes include number 6 (2/3 cup), number 8 (1/2 cup), number 10 (3/8 cup), number 12 (1/3 cup) number 16 (1/4 cup). Ladle sizes include 2 ounce (1/4 cup), 4 ounce (1/2 cup) 6 ounce (3/4 cup) 8-ounce (1 cup). A diet scale should be used to weigh meats. Review of the policy and procedure titled Menus dated 2023, showed menus are planned to meet the Dietary Reference Intakes (DRI; a set of scientifically developed reference values for nutrients) from the Food and Nutrition Board of the institute of Medicine. Menus will provide adequate nutrients to meet the special needs of the residents, including special dietary modifications. Menus will provide a variety of foods and indicate standard portions to be served. 1. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular textured, CCHO diets and Mechanical Soft diets (foods that can be easily chewed) received a piece of lemon cake. The spreadsheet also showed pureed (foods that do not require chewing) CCHO diets received pureed lemon cake. In interviews with DA 1 and DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed lunch trays with diet tickets that indicated regular textured, CCHO diets and CCHO Mechanical Soft diets, received a bowl of fruit cocktail on the tray. In addition, tray tickets that indicated pureed CCHO diets received a bowl of applesauce on the tray. The regular textured CCHO and Mechanical Soft CCHO diets did not have cake on the tray and the pureed CCHO diets did not have pureed cake on the tray. DA 1 confirmed CCHO diets were not served cake and regular texture CCHO diets and Mechanical Soft CCHO diets received fruit cocktail and pureed CCHO diets received applesauce. DS stated he instructed the staff to serve fruit cocktail and applesauce to CCHO diets because he thought the cake was too sweet. In an interview with Registered Dietitian 1 (RD 1) on 4/24/23 at 1:35 p.m., he stated CCHO should have received cake as indicated on the menu. 2. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular portion diets received a number 8 scoop (1/2 cup or 4 ounces) of Herb Yukon Potatoes and a number 8 scoop of Mixed Vegetables. In an interview with DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed [NAME] 1 used a 3-ounce ladle to serve potatoes and a 3-ounce ladle to serve vegetables to all regular portion/regular texture diets. DS confirmed [NAME] 1 served a smaller portion of potatoes and vegetables than what was indicated on the menu to regular portion/regular texture diets. 3. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed regular portioned pureed diets received a number 6 scoop (2/3 cup) of pureed pot roast, a number 10 scoop (3/8 cup) of pureed vegetables, and a number 10 scoop of pureed cake. An observation on 4/24/23 at 11:45 p.m., showed DS placed cake in a blender with thickened dairy beverage then blended the ingredients into a puree. DS used a number 8 scoop (1/2 cup) to place one scoop of pureed cake into individual bowls. In an interview with DS and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the bowls containing the of pureed cake prepared by DS were served to residents who received pureed diets (excluding residents on pureed CCHO diets). Also, [NAME] 1 used a number 8 scoop (1/2 cup) to serve pureed pot roast and number 8 scoop to serve pureed vegetables for all regular portion pureed diets. DS confirmed the portions of meat and vegetables [NAME] 1 served for the pureed diets were incorrect according to the menu. In an interview with DS on 4/25/23 at 10:30 a.m., he confirmed he served the wrong portion of pureed cake to pureed diets. 4. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed a small portion of potatoes was a number 16 scoop (1/4 cup) and a regular portion of meat was three ounces. In an interview with DS and [NAME] 1 and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the tray ticket for Random Resident 1 (RR 1) showed the Resident was on a No Added Salt Regular Portion diet with a large portion of vegetables and small portions of starch. [NAME] 1 served RR 1, two pieces of pot roast and a number 8 scoop (1/2 cup) of potatoes. [NAME] 1 stated he served RR 1 two pieces of pot roast because the resident was supposed to get double portions. DS weighed the meat on a scale served to RR 1. The scale showed the meat weight 5.7 ounces. DS confirmed RR 1 received almost double the amount of meat according to the tray ticket and the menu. [NAME] 1 also confirmed he served the incorrect portion of potatoes. In an interview on 4/25/23 at 10:30 a.m., DS stated he thought the tray tags had too much information for the [NAME] to read and some of the information on the tray tickets was confusing. 5. According to the Daily Spreadsheet Monday - Day 9 dated Spring/Summer 2023, and used for lunch on 4/24/23, showed Mechanical Soft diets received a number 8 scoop (1/2 cup) of pot roast. In an interview with [NAME] 1 and observation of lunch trayline which started at 12 p.m. on 4/24/23, showed the tray ticket for Resident 6 showed the Resident was on a Regular Mechanical Soft diet with small portions and large protein portions. [NAME] 1 served Resident 6 a number 12 scoop (1/3 cup) of mechanical soft pot roast. [NAME] 1 confirmed he did not serve a large portion of meat to Resident 6. In an interview on 4/25/23 at 10:30 a.m., DS stated he thought the tray tags had too much information for [NAME] 1 to read and some of the information on the tray tickets was confusing.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and facility document review, the facility failed to serve food that was palatable when the food was bland (lacking flavor) and the food was not maintained at a warm temperature. This failure had the potential for 34 residents to consume less food resulting in the consumption of fewer calories and nutrients provided by the planned menu, out of a facility census of 34. Findings: Review of the policy and procedure titled Meal Service Subject: Cultural Dining dated 2023, showed a possible problem during food service is maintaining food temperatures at the dining table. The procedures showed a solution for this problem is food should be 120 degrees or above upon arrival to the dining room. Review of the Daily Spreadsheet dated Tuesday - Day 3 and used for lunch on 2/14/23, showed the regular consistency food included Braised Pork Shoulder, Sauteed Broccoli Florets, and Hawaiian Rice. The pureed food included Braised Pork Shoulder Puree, Pureed Sauteed Broccoli Florets, and Seasoned [NAME] Puree. Review of the undated recipe titled Braised Pork Shoulder showed the ingredients included pork shoulder, fresh yellow onions, fresh carrots, a fresh garlic clove, fresh celery, olive oil, orange juice, cooking burgundy wine, and low sodium beef soup base. The recipe also showed for the pureed diet, to refer to the Pureed Meat recipe. Review of the undated recipe titled Sauteed Broccoli Florets (Fresh), showed ingredients included fresh broccoli florets, olive oil, a fresh garlic clove, crushed red pepper, and Mrs. Dash original blend seasoning. The recipe showed for the puree diet, to refer to the Pureed Vegetables Recipe. On 2/14/23 at 11:34 a.m., an observation and interview with [NAME] 2 and DSS 1, showed [NAME] 2 made pureed rice by adding scoops of cooked rice into a food processor and adding water. He mixed the contents then added more water. [NAME] 2 stated he used chicken base to cook the rice. He stated he did not use any other ingredients. Then [NAME] 2 pureed broccoli by adding broccoli from a pan on the stove into the food processor. The broccoli was a dull green and appeared limp. [NAME] 2 stated he boiled the broccoli and added salt and pepper. He said he did not add any other ingredients. [NAME] 2 stated he made a different broccoli for the regular textured diets. He said for the regular broccoli he added salt, pepper, garlic, and sage. He said he baked the regular broccoli in the oven. Next [NAME] 2 pulled a pork roast out of the oven. He sated the only ingredients he used to prepare the pork were salt and pepper. DSS 1 stated recipes should be followed. On 2/14/23 at 1:04 p.m., a food cart left the kitchen holding resident lunch trays and two test trays containing food to be assessed by the surveyors. On 2/14/23 at 1:04 p.m., when the last resident tray was served, the test trays were immediately assessed in the presence of DSS 1. One test tray contained same regular texture food served to residents for lunch. The second test tray contained the same pureed food served to residents for lunch. Temperatures of the food were measured by the surveyor with the surveyor's calibrated thermometer and by DSS 1 with a facility thermometer. The temperatures were as follows: regular textured pork 103.8 degrees Fahrenheit (F, surveyor temperature) and 100 degrees F (DSS1 temperature). Regular texture broccoli 98.1 degrees F (surveyor) and 100 degrees F (DSS1). Regular texture rice 95.7 degrees F (surveyor) and 89 degrees F (DSS1). Pureed pork 123.6 degrees F (surveyor) and 120 degrees F (DSS 1). Pureed broccoli 116.4 degrees F (surveyor) and 115 degrees F (DSS1). Pureed rice 121 degrees F and 120 degrees F (DSS1). The food was tasted. DSS 1 stated all the food was cold. Two surveyors who tasted the food also confirmed the food felt cool in the mouth and the temperature was not palatable, especially for the foods that were under 120 degrees F. DSS 1 also stated the food was bland (lacking flavor). The surveyors confirmed the regular and pureed broccoli tasted bland, the regular pork and pureed pork tasted bland, and the pureed rice tasted bland. In an interview on 2/15/23 at 10:13 a.m., [NAME] 2 stated he did have the ingredients to make the pork and the broccoli per the recipes, but he did not follow the recipes. On 2/16/23 at 8:58 a.m., [NAME] 2 stated there were no recipes for pureed meat or pureed vegetables. He also stated he did not have a seasoned rice recipe for the pureed diet. He said these recipes used to be available when the prior supervisor worked at the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and document review, the facility failed to store, prepare, and distribute in a safe and sanitary manner when: 1. Perishable and time/temperature control for safety (TCS) food (Time/Temperature for safety food means a food that requires time/temperature control for safety to limit pathogenic microorganism [an organism which can cause disease] growth or toxin [a naturally occurring organic poison] was not stored at a safe temperature (Cross-reference F801); 2. Sanitizer strength for a low temperature dish machine was not monitored and the dish machine water temperature was below the recommended temperature (Cross-reference F801); 3. Surface sanitizer was not used on appropriately for kitchen and equipment surfaces, such as countertops and food processors, to ensure surfaces sanitized (Cross-reference F801); 4. The ice machine was not clean; 5. The juice machine was not clean; 6. A reach-in food refrigerator was not clean; 7. A wall in a food preparation area was not clean and the area above the stove was not clean; 8. A fresh air intake vent in a dry food storage/freezer room was not clean; 9. Proper hand hygiene and glove use was not performed; 10. A food storage freezer was not monitored to ensure food was frozen solid; 11. Stacked pans were stored wet and were not clean; 12. Food was not stored safely when a scoop was stored inside the flour container; 13. Food was not stored safely when a bulk container of flour was stored on the floor; 14. A blender was not maintained in good condition; 15. Food was missing dates to show expiration and/or when to use-by; and 16. There was no airgap (a visible gap between the drainpipe and a drain) for the food preparation sink. These failures had the potential to cause food borne illness to 34 residents who receive food from the kitchen out of a facility census of 34. Findings: 1. Review of the policy and procedure titled Sanitation and Infection Control Subject: Refrigerated Storage dated 2023, showed refrigerator temperatures should be recorded two times each day. It is recommended temperatures e recorded in the a.m. (morning) immediately after opening the kitchen and the p.m. (evening) before closing. Perishable foods should be stored less than or equal to 41 degrees F (Fahrenheit). Review of the policy and procedure titled Food Preparation Subject: Food Defrosting Methods dated 2023, showed food will be thawed in a manner as to keep food out of the danger zone (41 - 140 degrees F) for the entire thawing process. On 2/13/23 at 9 a.m., and observation and concurrent interview with [NAME] 1 showed a 3-door reach-in refrigerator filled with food. An internal thermometer showed the refrigerator was 50 degrees Fahrenheit (F). The surveyors asked [NAME] 1 if there was documentation for refrigerator temperatures. [NAME] 1 showed the surveyors a clipboard hanging on the wall next to the refrigerator. He showed that the last documented temperatures for the refrigerator were from November 2022. Then he looked through a binder and found documented refrigerator temperatures documented for 1/25/23. [NAME] 1 was not able to find any refrigerator temperature documentation for February. Review of the document titled Food Temperature/Sanitation Record dated 1/25/23 showed two documented refrigerator temperatures documented at 5:30. As the initial tour continued on 2/13/23 at 10 a.m., the three-door, reach-in refrigerator was observed in the presence of DSS 1 and Diet Aide 3 (DA 3). The thermometer inside the refrigerator showed 46 degrees F. Food temperatures were measured with calibrated surveyor thermometers. A nutrition supplement shake taken from a box holding multiple shakes and dated 2/7 had a temperature of 48.6 degrees F. DA 3 stated she thought the shakes had been in the refrigerator and not removed from refrigeration for 5 days. A yogurt in an individual container was 43.9 degrees F. Sour cream from an opened container was 43.5 degrees F. DSS confirmed the temperatures taken. She said the temperature of food stored in the refrigerator should be 34 degrees or lower. Other items in the refrigerator included thawing raw chicken in a metal container with a label which showed it was placed in the refrigerator on 2/11 and was to be used by 2/16 and 2 packages of raw thawing pork with a label that showed it was placed in the refrigerator on 2/12 and was to be used by 2/16. The chicken appeared soft and fully thawed and the pork was soft to the touch and felt fully thawed, and there were red juices inside the metal container holding the thawing pork. [NAME] 1 stated the raw chicken in the refrigerator was leftover and he might cook it tomorrow. The temperature of the chicken stored in the refrigerator measured 44.6 degrees F. DSS 1 stated thawing meat should only be held for 3 days. In an interview on 2/13/23 at 2:55 p.m., the DSS 1 stated after reviewing refrigerator temperature logs, the last documentation available was on 1/25/23. On 2/14/23 at 8:22 a.m., an observations and concurrent interviews with Diet Aide 1 (DA 1) and [NAME] 2, showed DA 1 and [NAME] 2 working in the kitchen without a supervisor. The 3-door refrigerator temperature was checked. The thermometer read 42 degrees F. [NAME] 2 and DA 1 stated they did not check the refrigerator temperature today. The Record of Refrigeration Temperatures dated February 2023 was blank in the space designated to record a temperature on 2/13/23. Temperatures of food stored in the refrigerator were measured with surveyor calibrated thermometers. Tuna salad dated 2/10/23 was 46.2 degrees F. Cut cantaloupe dated 2/11 - 2/16 was 44.8 degrees F. An undated package of raw, thawed pork was 48 degrees F and 46.8 degrees F (the temperature was measured in two places inside the pork), shredded cabbage stored in an opened plastic bag labeled prep [preparation] date 2/10/23 Use by 2/16/23 was 46.2 degrees F, shredded mozzarella cheese in an opened plastic bag labeled prep 2/8/23 use by 3/8/23 was 44.4 degrees F, shredded cheddar cheese in an opened plastic bag labeled prep date 2/9/23 use by 3/9/23 was 46 degrees F, an opened container of Caesar salad dressing was 45 degrees F, a nutrition supplement shake in a cardboard box dated February 7 and containing multiple shakes all dated use by Feb [February] 18 was 48.4 degrees F. DA 1 and [NAME] 2 stated all the food measured for temperature were stored in the refrigerator overnight and not removed from refrigeration that morning. In an interview and observation with DSS 1 and [NAME] 2 on 2/14/23 at 11:20 a.m., showed DSS 1 arrived at the facility. The surveyor informed the DSS 1 of the food temperatures found in the refrigerator at 8:22 a.m. The DSS stated okay. [NAME] 2 stated he documented the refrigerator temperature at 11:10 a.m. He said the refrigerator temperature should not be above 42 degrees F and 45 degrees F was okay because the refrigerator temperature can go up when the door was opened and closed many times. DSS 1 informed [NAME] 2 the refrigerator temperature had to be 41 degrees or below. Review of the document titled Record of Refrigeration Temperatures dated February 2023, showed 45 degrees documented for the refrigerator on 2/14/23. Directions typed at the bottom of the documented showed Refrigeration: Not greater than 41 degrees F . Report to Supervisor when recorded temperatures are not adequate. On 2/14/23 at 1:30 p.m., an observation and concurrent interview with the DSS 1 showed two thermometers on inside the 3-door reach-in refrigerator with temperatures measuring 42 degrees F and 45 degrees F. The DSS 1 stated new thermometers were needed and the food inside the refrigerator was okay. On 2/14/23 at 1:47 p.m., an observation and interview with the DSS 1 and DA 1, showed the same foods stored in the 3-door reach-in refrigerator that were observed in the morning (on 2/14/23 at 8:22 a.m.). The temperature of the food was measured with the surveyors' calibrated thermometers in the presence of DSS 1. Two temperatures were taken of the raw, thawed pork and were 48.7 degrees F and 46.8 degrees F. The cut cantaloupe was 45.5 degrees F, shredded cabbage in an opened plastic bag dated 2/10/23 - 2/16/23 was 46.8 degrees F, the opened bag of shredded cheddar cheese dated 2/9/23 - 3/9/23 was 47.5 degrees F, opened bag of shredded mozzarella cheese 46.9 degrees F, a nutrition supplement shake from the cardboard box dated 2/7 was 48.2 degrees F, the opened container of Caesar dressing was 48.2 degrees F. DA 1 stated all the food that was measured for temperatures were not removed from refrigeration that day. DSS 1 stated the foods with high temperatures needed to be discarded. The surveyor asked if other food stored in the refrigerator was safe, she stated she needed to speak with RD 1. 2. During a review of the facility's P & P titled, Sanitation and Infection Control Subject: Dish Washing Procedures (DishMachine) dated 2023, showed the dish machines will be used per manufacturer's guidelines. A chemical low temperatures dish machines must maintain a water temperature of 120 - 140-degree F. Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM (parts per million) of chlorine at the dish surface or according to manufacturer's specifications. Obtain test strips from your local chemical distributor for testing PPM on low temperature machine. On 2/13/23 at 9:30 a.m., an observation and interview with DA 3 and [NAME] 1, showed DA 3 washed dishes including used cups, bowls, trays, and plate dome covers (used to cover food on a plate and helps maintain food temperature), returned from the breakfast meal. The temperature dial on the dish machine showed the wash and rinse temperatures were both 90 degrees F. DA 3 stated the water was hot, so it was okay. She also stated she thought the water temperature should be 110 degrees F to 115 degrees F. She stated she did not check the sanitizer in the machine and did not know who was responsible for checking it. When the surveyor asked if there were test strips, to test the sanitizer, DA 3 could not find any to check chlorine sanitizer used in the machine. Then DA 3 ran the dish machine and checked the temperature dial. She stated the temperature was 86 degrees F, then continued to wash dishes. [NAME] 1 also stated he did not check the sanitizer strength of the dish machine. The information plate attached to the side of the dish machine showed the minimum wash temperature was 120 degrees F and the minimum rinse temperature was 120 degrees F. The information plate showed the minimum chlorine required was 50 ppm. During an observation and concurrent interview with DSS 1 on 2/13/23 at 9:35 a.m., DSS 1 watched a dish machine cycle and stated the dish machine temperature was too low and dishwashing had to stop. She stated everything washed that morning had to be rewashed after the dish machine was fixed. She also stated it did not appear the sanitizer chemical was running through the hose into the machine and that the chlorine sanitizer container connected to the dish machine was empty. In an interview with DSS 1 on 2/13/23 at 12:23 p.m., she confirmed there were no test strips available needed to test the sanitizer in the dish machine. In an interview on 2/13/23 at 2:55 p.m., the DSS 1 stated after reviewing dish machine documentation logs for temperature and sanitizer strength, the last documentation available was on 1/25/23. On 02/15/23 at 10:13 a.m., an observation and interview with DA 1, DA 1 washed dishes and provided the Dishmachine Temperature Log (Low Temperature) she used to document the dish machine temperature and sanitizer strength. The log did not indicate the month but there was documentation by the columns for the 14th and 15th. There was no documentation for the 1st through the 13th. The documentation showed wash temperatures were recorded as well as the sanitizer strength, and rinse temperatures were not recorded. On 2/16/23 at 9:59 a.m., and observation and interview with DA 1, showed DA 1 washed dishes. The temperature dial on the machine was observed. The wash temperature was 116 degrees F, and the rinse temperature was 115 degrees F. DA 1 confirmed the temperature was low and ran the dish machine three more times and stated the dish machine did not reach 120 degrees F. 3. Review of the policy and procedure titled Sanitation and Infection Control Subject: Sanitizing Equipment and Surfaces with Quaternary Ammonium (Quat) Sanitizer dated 2023, showed equipment and surfaces may be sanitized using quat solution after each use and more often as needed. Quat levels will be checked and recorded every two hours for buckets, or more often as needed to ensure equipment and surfaces are sanitized appropriately. The procedures included buckets were to be filled with a quat solution and appropriate quat levels were to be checked by inserting a quat test strip into the bucket of solution. Test strips could range between 200 - 400 ppm. Results for the buckets would be recorded every 2 hours. According to the 2022 Federal Food Code, equipment food-contact surfaces and utensils are to be sanitized before use and after cleaning. During the initial tour of the kitchen on 2/13/23 at 10:15 a.m., an observation and concurrent interview with the DSS 1 and [NAME] 1, showed DSS 1 looked for quaternary ammonia sanitizer to clean surfaces such as countertops. She stated she could not find any in the kitchen. [NAME] 1 stated he did not use sanitizer for kitchen surfaces, such as countertops. He stated he only used the soap detergent that was hooked up to a dispenser over the 2-compartment sink. [NAME] 1 pointed to the hose over the 2-compartment sink which attached to a container of detergent under the sink. In an interview on 2/15/23 at 1:05 p.m., Diet Aide 2 (DA 2) stated he cleaned the juice machine in the afternoons and did not have directions to follow. He stated he wiped down the outside of the machine with soapy water then sanitized the outside of the machine with a quat sanitizing solution. He demonstrated how he made the sanitizing solution by placing 2 capfuls of quaternary ammonia into a pan of water. He stated he did not know how to test the strength of the solution and asked the surveyor if they could teach him. The solution was tested by the surveyor with a quaternary ammonia test strip and compared to the color chart on the test strip container. DA 2 stated the strip showed the solution was 500 ppm. DA 2 repeated the steps for mixing the sanitizer solution with one cap of quaternary ammonia in a pan of water instead of 2 caps and compared the test strip to the color chart and confirmed the solution strength was between 100 and 200 ppm. On 2/14/23 at 11:34 a.m., an observation and interview with [NAME] 2 and DA 1, showed [NAME] 2 used a sanitizer solution in a red bucket to wipe down a countertop where he prepared food for the lunch meal. [NAME] 2 also wiped down the outside of the food processor he used to puree food, with a cloth that was stored in the sanitizer bucket. The surveyor asked DA 1 to test the sanitizer strength for the sanitizer in the red bucket. DA 1 removed a test strip from a quaternary ammonia test strip container and held the test strip in the sanitizer in the sanitizer solution for 25 seconds. When asked if she knew how long to hold the test strip in the sanitizer, she stated 10 seconds. The sanitizer was tested again, and a test strip was held in the sanitizer solution for 10 seconds. The test strip did not change color and remained light yellow. DSS 1 stated the sanitizer strength was too low. Review of the directions on the instructions on the test strip container showed to dip the strip into the quat solution for 10 seconds. The color chart on the test strip container showed if the test strip did not change color, the strength of the sanitizer was 0 ppm. 4. During an observation of the ice machine and concurrent interview with DSS 1 on 2/14/23, at 11:02 am, the ice chute inside the ice bin was wiped with a white napkin and pink and black, slimy residue wiped off, onto the napkin. DSS 1 confirmed the residue that was wiped off from the ice machine chute. During an observation of the ice machine and interview with the Maintenance Director (MD) on 2/14/23, at 2:05 pm, MD stated the last time he cleaned the ice machine was September 2022. MD removed the plastic cover over the water evaporator plate (where ice is formed). There was white and pink residue on the inside surface of the cover. The pink residue came off when it was wiped with a napkin. On the plastic frame of the surrounding the evaporator plate, there was a significant amount of slimy yellow, clear, and pink residue. There was also a significant amount of thick, black, slimy residue. The residue came off easily when it was wiped with a napkin. MD confirmed he did not have the manufacturer's manual and did not use the manufacturer's directions when he cleaned the ice machine. MD provided the documentation to show the last time he cleaned the ice machine. Review of the document titled Monthly Ice Machine was dated 9/22 and was signed by MD. MD confirmed the last time he cleaned the ice machine was September 2022. Review of the manufacturer's manual for the ice machine dated 2008, showed it is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained. The manual gave specific directions were on how to clean the machine. Review of the facility's P & P titled, Sanitation and Infection Control Subject: Cleaning Ice Machine dated 2023, showed ice machines will be cleaned and sanitized once a month. Follow the manufacturer recommendations to clean the internal mechanisms of the ice machine. If another department is responsible for cleaning the ice machine, make sure the process is being followed according to policy for technique and time frame. The individual responsible must be properly trained by the manufacturer with approved competency. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch. 5. In an interview on 2/15/23 at 1:05 p.m., Diet Aide 2 (DA 2) stated there was no cleaning schedule to follow for cleaning in the kitchen. He also stated he cleaned the juice machine in the afternoons and did not have directions to follow. On 2/17/23 at 10:42 a.m., during an observation and interview with DSS 2, removed the nozzles from the juice machine and stated there was a lot of residue and mold inside the nozzles. The inside of the nozzles had a thick layer of yellow and white slimy residue on the inside surface. DSS 2 stated there use to be cleaning instructions for the juice machine attached to the side of the refrigerator which was adjacent to the juice machine, and he confirmed the cleaning instructions were no longer posted. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch. 6. During the initial tour of the kitchen, an observation on 2/13/23 at 9:30 a.m., showed a reach-in freezer stored ice cream products, located in the dry storeroom. There was a significant amount of white and multicolored debris that resembled food crumbs in the crevices of rubber gasket (a rubber seal that surrounds inside of the freezer door to help the freezer maintain temperature by sealing the cold air inside the unit) at the bottom of the inside freezer door. In addition, there was debris that resembled food crumbs on bottom, inside surface of the freezer, as well pink and brown residue that looked like drips from food and/or beverage products. Pink residue was also imbedded around crevices at the bottom of the freezer. During an interview and concurrent observation with DSS 1 on 2/15/23 at 4:55 p.m., DSS 1 confirmed the reach-in freezer was dirty when she observed it on 2/13/23. She stated the kitchen staff did not have a cleaning schedule to follow. Review of the facility's P & P titled, Sanitation and Infection Control Subject: Cleaning Refrigerators dated 2023, showed reach-in refrigerators will be cleaned and sanitized once a week, and messes and spills will be cleaned as they occur. Review of the policy and procedure titled Sanitation and Infection Control Subject: Cleaning Schedules dated 2023, showed a cleaning schedule should indicate the frequency of cleaning tasks and designated to specific positions. Suggested cleaning schedule for the kitchen showed to clean reach-in freezers weekly. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch and nonfood-contact surfaces of equipment shall be kept free of an accumulation of food residue and other debris. 7. During the initial tour of the kitchen, an observation on 2/13/23 at 9:14 a.m., showed fuzzy gray residue resembling dust, yellow residue, and a significant amount of small white and multicolored loose debris, on the gas piping connected to the wall behind the stove. Also, there was a fuzzy residue resembling dust on wires directly above the stove. During this time there was food being prepared on the stove. In an interview on 2/15/23 at 1:05 p.m., DA 2 stated there was no cleaning schedule to follow for the kitchen. On 2/15/23, at 4:56 p.m., DSS 1 confirmed there was loose and fuzzy debris on the pipes behind the stove and on the wiring above the stove. DSS 1 stated the area needed to be cleaned. Review of the policy and procedure titled Sanitation and Infection Control Subject: Cleaning Schedules dated 2023, showed a cleaning schedule should indicate the frequency of cleaning tasks and designated to specific positions. Best practice would include a deep cleaning of the kitchen by an outside cleaning agency quarterly. In times of kitchen staff shortages, the cleaning of the kitchen needs to be maintained, either by internal housekeeping staff and/or outside cleaning agencies. Suggested cleaning schedule for the kitchen showed to clean walls weekly. According to the 2022 Federal Food Code, walls and utility service lines are to be constructed to ensure that regular and effective cleaning is possible. 8. An observation in the storage/freezer room and interview with MD on 2/15/23 at 5:25, showed an air vent with fuzzy gray debris throughout the surface of the vent screen. There were also cobwebs on the ledge below the vent. MD stated that vent was a fresh air intake vent, so air was drawn into the room through the vent. He stated the vent was dirty and dusty and he was responsible for cleaning the vent, but never did. Review of the facility's P & P titled, Sanitation and Infection Control: Canned and Dry Goods Storage dated 2023, showed food storage areas will be cleaned and maintained. Review of the policy and procedure titled Sanitation and Infection Control Subject: Cleaning Schedules dated 2023, showed a cleaning schedule should indicate the frequency of cleaning tasks and designated to specific positions. Best practice would include a deep cleaning of the kitchen by an outside cleaning agency quarterly. In times of kitchen staff shortages, the cleaning of the kitchen needs to be maintained, either by internal housekeeping staff and/or outside cleaning agencies. Suggested cleaning schedule for the kitchen areas showed to clean screens and vents monthly. 9. An observation on 2/14/23 at 11:34 a.m., showed [NAME] 2 prepared pureed food. [NAME] 2 used the sprayer on the dirty side of the dish machine to rinse the food processor he used to puree food. [NAME] 2 did not wash his hands after handling the sprayer on the dirty side of the dish machine. Then [NAME] 2 removed clean items from the dish machine including a scoop used for scooping food and a built-up plate (a plate with higher sides than an average plate and used as an assistive device to help with scooping food onto a utensil). [NAME] 2 carried the scoop, the built-up plate, and the rinsed food processor back to the food preparation area and prepared pureed food. As [NAME] 2 prepared the pureed food he scratched his head. The hairnet [NAME] 2 wore was made of netting, which allowed his fingers to come into contact with his hair when he scratched his head. [NAME] 2 continued to prepare food after scratching his head. An observation on 2/14/23 at 12:20 p.m., showed [NAME] 2 pulled a pork roast out of the oven. [NAME] to put gloves on and cut the pork. [NAME] 2 did not wash his hands before putting the gloves on. In an interview on 2/15/23 at 4:56 p.m., DSS 1 stated staff had to wash hands before putting gloves on, after touching hair, and after touching anything dirty, such as anything on the dirty side of the dish machine. Review of the policy and procedure titled Sanitation and Infection Control Subject: Handwashing dated 2023, showed the food service workers will keep their hands and exposed portion of their arms clean. Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment. Hands are to be washed after doing cleaning procedures, before handling foods, and after touching the face or hair. According to the 2022 Federal Food Code, food employees are to clean/wash their hands and exposed portions of their arms before engaging in food preparation including working with exposed food and clean equipment and utensils. Washing hands is to occur after touching bare human body parts other than clean hands and clean, exposed portions of arms; after handling soiled equipment; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. 10. An observation and interview with Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 4 (LVN 4) on 2/13/23 at 12:25 p.m., showed a small reach-in refrigerator/freezer was located in the medication room at nursing station two. LVN 1 stated the refrigerator/freezer was where the facility stored resident food brought in by family and visitors. The small freezer compartment did not have a thermometer inside to show the temperature. The freezer compartment was filled with ice cream bars that were not frozen and soft when pressed. LVN 1 stated the ice creams were for Resident 16. LVN 4 confirmed that the ice creams were soft, and Resident 16 might not eat them if they were soft. LVN 4 also confirmed that the freezer had no thermometer. LVN 4 provided the temperature log for the refrigerator/freezer. Review of the Temperature Logs dated February 2023 showed the refrigerator temperature was measured twice a day. LVN 4 confirmed freezer temperatures were not documented on the log. Review of the policy and procedure titled Sanitation and Infection Control Subject: Freezer Storage dated 2023, showed each freezer must have an internal thermometer that is easily visible. Freezer temperatures should be recorded two times each day. It is recommended temperatures be recorded in the a.m. and the p.m. The freezer should be maintained at a temperature equal to or less than 0 degrees F. According to the 2022 Federal Food Code frozen shall be maintained frozen. 11. During the initial tour of the kitchen, a concurrent observation and interview with [NAME] 1 on 2/13/23, at 9:17 a.m., showed various sized metal pans, stored on a shelf for cleaned items, above the two-compartment sink. Four metal pans were wet and stacked within one another. Three of the four pans had thick white residue inside surface that resembled food residue. [NAME] 1 stated it was okay to stack the pans when they were wet and confirmed pans had white residue inside. He stated the pans with the residue had to be rewashed. During an interview on 2/13/23 at 5 p.m., with DSS 1, DSS 1 stated wet pans should be air dried before stacking and storing, and the dirty pans must be rewashed in the dish machine before storing. Review of the facility's P & P titled, Sanitation and Infection Control Subject: Dishwashing Procedures (Dishmachine) dated 2023, showed all the dishes should be inspected after coming out of the dish machine and if the dishes are not clean then they should be washed again in the dish machine. Allow racks of dishes/trays/utensils to air dry. Do not stack wet dishes or trays. According to the 2022 Federal Food Code, after cleaning and sanitizing, stored equipment and utensils are to be air-dried before storing. 12. During the initial tour of the kitchen, an observation on 2/13/23 at 9:10 a.m., showed a plastic container holding flour was stored on a shelf next to the stove. The container of flour had a scoop stored inside touching the flour. During a concurrent observation and interview on 2/13/23 at 12:20 p.m., with DSS 1, DSS 1 used flour from the plastic container to make gravy. DSS 1 confirmed the scoop was stored inside the container with the flour and stated the scoop should never be left inside the flour container. Review of the facility's P & P titled Sanitation and Infection Control subject: Canned and Dry Goods Storage dated 2023, showed scoops are to be stored in a separate area, not inside food containers, and need to be cleaned each time they are used. 13. During an observation in the food storage/freezer room and interview with DSS 1 on 2/15/23, at 5:24 p.m., there was flour in a bulk bag inside a plastic container stored on the floor in the corner of the room. Other bulk foods in plastic containers, such as powdered sugar and rice, were stored on a food storage rack. DSS 1 stated the flour was not supposed to be stored on the floor and had to be at least 6 inches off the floor. Review of the facility's P & P titled, Sanitation and Infection Control Subject: Canned and Dry Goods Storage dated 2023, showed all food items will be stored off the floor, on racks, shelves, or other surfaces. Food supply should be stored 6 inches off the floor. 14. During the initial tour of the kitchen, an observation on 2/13/23 at 9:12 a.m., showed a blender stored on the countertop next to the stove. The coating over the buttons used to operate the blender were significantly chipped peeled and had a rough surface. There was yellow residue imbedded in the crevices around the buttons. During an interview and observation, on 2/15/23 at 4:57 p.m., DSS 1 looked at the blender and stated the blender was chipped and cracked and not safe to use. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment are to be free of unnecessary crevices and designed and constructed to allow easy cleaning and to facilitate

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices, when following was noted: 1. Oxygen (O2) tubing for Resident 20 was unlabeled/ undated and was touching the floor. 2. Resident 24's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask and tubing was left uncovered on the nightstand. The tubing was not labeled and or dated with yellowish tinged discoloration. 3. Facility did not create and maintain an active water management plan. The above failures placed Residents 20 and 24 at risk for respiratory and skin infections, not having a water management plan placed all 34 residents at risk for gastrointestinal infection (gut inflammation caused by consuming contaminated water or food, characterized with stomach pain, nausea, vomiting, diarrhea, fever etc.) Findings. 1. During a review of Resident 20's Resident Face Sheet printed on 02/13/23, the record indicated Resident 20 was admitted to the facility on [DATE]. During a record review of the Minimum Data Set (MDS- an assessment used to guide care) dated 02/07/23, the assessment indicated Resident 20 had a Brief Interview of Mental Status (BIMS) score of 09 out of 15, indicating moderately impaired cognition. During an observation on 02/13/23, at 10:43 a.m., Resident 20 was receiving O2 at 2.5 liters/minute (L/min), and the O2 tubing was undated and lying strewn on the floor. During another observation on 02/14/23, at 10:00 a.m., O2 tubing for Resident 20 was again strewn on the floor. During an observation and interview on 02/13/23, at 11:10 a.m., with the Director of Nursing (DON), Resident 20's O2 tubing was observed. The DON stated the O2 tubing being on the floor for Resident 20 was an infection control issue, there should be a label with date, and it should be changed once a week. During an interview, and record review on 02/13/23, at 01:41 p.m., with DON, Resident 20's s Physician's orders dated 2/2023 were reviewed. The DON stated she was unable to find a physician order with a frequency to change the O2 tubing. 2. During a review of Resident 24's Resident Face Sheet printed on 02/13/23, the record indicated, Resident 24 as admitted to the facility on [DATE]. During a record review of the Minimum Data Set (MDS- an assessment used to guide care) dated 02/08/2023, the assessment indicated Residents 24 had a BIMS score of 15 out of 15, indicating intact mental status. During an observation and interview with Resident 24 on, 02/13/23, at 10:55 a.m., Resident 24's nebulizer mask and tubing was observed. The nebulizer mask was yellowish tinged and had condensation (wetness) in the interior portion. The nebulizer tubing was undated, dangling all over the floor, and the nebulizer mask was on the bedside table next to a clear cup of yellow color liquid, and open packets of crackers (a flat, dry baked biscuit typically made with flour). Resident 24 stated, she had the same nebulizer mask and tubing since 9/2022, when she arrived at the facility. Resident 24 stated, she had never seen facility staff change the tubing or clean the mask. During an observation and interview on 02/13/2023, at 11:20 a.m., with the DON, Resident 24's nebulizer mask and tubing was observed. The DON stated, Resident 24's nebulizer mask and tubing did not look to have been changed in a long time. The DON stated, tubing should be labeled with a date, and the mask should be dismantled, rinsed off, air dried and placed in clean paper bag. During an interview, and record review on 02/13/2023, at 1:30 p.m., with DON, Resident 24's Physician orders in Electronic Health Record were reviewed. The DON stated, she was unable to find physician order for Nebulizer kit care. The DON stated, she was unaware of how long Resident 24's nebulizer mask and tubing had not been cleaned and changed. DON stated, a physician order for Nebulizer Kit care should include frequency to change and clean the nebulizer kit. During an interview on 02/17/23, at 9:35 a.m., the DON stated, the risk of the O2 and Nebulizer tubing laying of the floor placed Resident 20 and Resident 24 at risk for respiratory and skin infection. During a record review of Oxygen & Respiration policy dated 05/01/2015, under section Oxygen Administration showed Label mask or cannula with date opened, and under section Nebulizer Use showed The equipment is changed 72 hours, Record in eTAR [electronic Treatment Administration Record]. Each patient has own breathing circuit (nebulizer, tubing, and mouthpiece), Through proper cleaning, sterilization, and storage of equipment, organisms can be prevented from entering the lungs. 3. During an observation and interview on 02/17/23, at 12:50 p.m., with DON, the two outdoor water fountains were observed in the patio. Both fountains had plant debris and moss growth. DON stated, she was not aware that the facility needed to maintain a water management program with an assessment to identify where water borne pathogens could grow and spread; measures to prevent the growth of potential waterborne pathogens and how to monitor them. The DON stated, the Maintenance Director (MD) was responsible for the cleaning the two outdoor water fountains. During an interview and record review on 02/17/23, at 1:00 p.m., in MD's office, DON stated, that she was not able to locate the Water Management Plan and the maintenance log. During a telephone interview on 02/17/23, at 1:20 p.m., with MD, MD stated he had been working at the facility for over a year and he did not develop a water management plan. MD sated he cleaned the two water fountains without any cleaning agents a few months ago and was unable to state the exact date of the cleaning service. During an interview on 02/17/23, at 2:00 p.m., ADM stated, facility did not have a Water Management Plan. ADM stated, an outside vendor came in to collect the water samples to test for legionella only on 2/15/23, with pending results.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to have a qualified and certified Infection Preventionist (IP) (a professionally trained individual responsible for facility's Infection Prevention and Control Program) staff for over two years. This failure resulted in facility not having a qualified staff responsible for assessing, developing, implementing, monitoring, and managing facility's Infection Prevention and Control Program and placed 34 residents at risk for infections. Findings A review of the Resident Census dated February 13, 2023, showed the facility had a total number of 34 residents in the facility. During an interview and record review on 02/14/23, at 10:43 a.m., DON's training certificate titled Module 1- Infection Prevention and Control Program dated 5/8/20 was reviewed. The DON stated, she had completed only Module 1 out of a total 24 required Modules for the completion of IP course. The DON stated, she had been performing IP duties since 2021 without a certification. The DON stated, she did not complete the IP certification course since 2020, as she was too busy to complete it. During an interview on 02/17/23, at 09:13 a.m., with Administrator (ADM), the ADM stated, to her knowledge the DON completed the IP training, however, did not know which course she took to be a qualified IP. During an interview on 02/17/23, at 09:20 a.m., with Regional Administrator (RADM), the RADM stated, he was the former administrator at the facility. RADM stated the IP role was a shared role between the DON and the Minimum Data Set Coordinator (MDSC1- a licensed staff responsible for completing resident assessments used in care planning) but he did not verify their certifications. During an interview on 02/17/23, at 09:43 a.m., the MDSC 1 stated, she primarily worked as an MDS Coordinator to complete the MDS assessments for residents residing at the facility. MDSC1 stated, she was helping the DON to provide Infection Prevention and Control related in-services and trainings to the staff but did not attend any IP certification training and was not a certified IP.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and facility document review, the facility failed to maintain the 2-compartment sink for manual warewashing when there were no stoppers available to allow the sinks to be filled. This failure did not allow the kitchen staff to follow the appropriate procedures for cleaning equipment and utensils used for food preparation when the dish machine was not working which led to the potential for food borne illness for 34 residents who received food from the kitchen out of a facility census of 34. Findings: Review of the policy and procedure titled Sanitation and Infection Control Subject: Warewashing (Hand Washing Method) dated 2023, showed when a two-compartment sink is used, compartment one is for washing and compartment 2 is for rinsing and sanitizing. For sanitizing, items are to be: immersed or at least 30 seconds if hot water of 171 degrees F or more is used, immersed for at least 30 seconds in a chlorine solution of 100 parts per million (ppm), immersed for at least 1 minute in an iodine solution of 25 ppm, or immersed for at least 1 minute in a quaternary ammonium solution of 200 ppm. In an observation and concurrent interview with [NAME] 2 on 2/14/23 at 9:10 a.m., [NAME] 2 demonstrated how he manually washed and sanitized items using the 2-compartment sink. Inside both sinks was a black, plastic tub. The tubs were less than half the depth of the sink. [NAME] 2 stated he filled one tub with water to wash items. He stated after rinsing the items, he sanitized items in the second tub. He said for large items such as large pans that did not fully fit in the tubs, he wiped the outside of the pan with a rag and sanitizer. He stated he could not fill the sinks to wash and sanitize because he did not have stoppers to plug the sinks.

Dec 2019 1 deficiency

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide no less than 80 square feet per resident for one of 25 rooms (room [ROOM NUMBER]). This failed practice had the potential to result in lack of sufficient space for staff to deliver care and provide storage space for resident belongings. Findings: During the initial tour at 9:36 a.m. on 12/3/19, the living space for room [ROOM NUMBER] was observed. room [ROOM NUMBER] had 4 beds and measured 293 square feet, providing 73.25 square feet per resident. Residents in the affected rooms had privacy, storage space for personal belongings and there were no complaints received from those residents. The facility's staff were able to provide nursing services to meet the individual needs of each resident within the affected room. During a group interview on 12/3/19 at 1:30 p.m., the residents stated they had no issues with their private space and had enough room for their personal items. There were no negative consequences attributable to the decreased space in room [ROOM NUMBER] nor were there any safety concerns noted. In an interview on 12/5/19 at 12:20 p.m., Resident 34 stated his room was fine and he could easily get in and out. In a concurrent observation, Resident 34 was observed in his wheelchair wheeling himself to the side of his bed without obstruction. In an interview at 2:00 p.m. the facility's Administrator (ADM) stated the facility would be requesting a room waiver for room [ROOM NUMBER].

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 24% annual turnover. Excellent stability, 24 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), Payment denial on record. Review inspection reports carefully.
• 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $11,170 in fines. Above average for California. Some compliance problems on record.

Bottom line: Mixed indicators with Trust Score of 61/100. Visit in person and ask pointed questions.

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About This Facility

What is St John Kronstadt Convalescent Center's CMS Rating?

CMS assigns ST JOHN KRONSTADT CONVALESCENT CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is St John Kronstadt Convalescent Center Staffed?

CMS rates ST JOHN KRONSTADT CONVALESCENT CENTER's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 24%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at St John Kronstadt Convalescent Center?

State health inspectors documented 23 deficiencies at ST JOHN KRONSTADT CONVALESCENT CENTER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 20 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates St John Kronstadt Convalescent Center?

ST JOHN KRONSTADT CONVALESCENT CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 49 certified beds and approximately 43 residents (about 88% occupancy), it is a smaller facility located in CASTRO VALLEY, California.

How Does St John Kronstadt Convalescent Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, ST JOHN KRONSTADT CONVALESCENT CENTER's overall rating (4 stars) is above the state average of 3.2, staff turnover (24%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting St John Kronstadt Convalescent Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is St John Kronstadt Convalescent Center Safe?

Based on CMS inspection data, ST JOHN KRONSTADT CONVALESCENT CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at St John Kronstadt Convalescent Center Stick Around?

Staff at ST JOHN KRONSTADT CONVALESCENT CENTER tend to stick around. With a turnover rate of 24%, the facility is 22 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was St John Kronstadt Convalescent Center Ever Fined?

ST JOHN KRONSTADT CONVALESCENT CENTER has been fined $11,170 across 1 penalty action. This is below the California average of $33,191. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is St John Kronstadt Convalescent Center on Any Federal Watch List?

ST JOHN KRONSTADT CONVALESCENT CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 49
Avg. Residents: 43
Occupancy: 88.4%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
Low Turnover: +5
1 Immediate Jeopardy citation: -12
23 Deficiencies: -10
Fines ($11,170): -2
Final Score: 61/100

Nearby Alternatives

ST PAUL'S TOWERS 5-star THE VINEYARDS HEALTHCARE CENTE... 5-star OAKLAND HEALTHCARE & WELLNESS ... 5-star

View all in CASTRO VALLEY →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555016