**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pain medication was administered as prescribed for Resident 1. This failure had the potential to result in uncontrolled pain management and adverse outcomes for Resident 1 (refer to Intake 2573274).Findings: During a review of Resident 1's face sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, metastatic (the spread of cancer cells from the place where they first formed to another part of the body) prostate cancer, and muscle weakness. During a review of the facility's policy and procedure titled, Medication Administration, General Guidelines (SNF), dated 4/21/25, the P&P indicated, Medications are administered only by nursing . 1. As Ordered: Medications are administered in accordance with and with orders of the prescriber. During a concurrent interview and record review on 8/20/25 at 10:23 AM with the LVN 1, the physician order for Oxycodone (narcotic pain medication usually prescribed for severe pain) 5 milligrams (mg) immediate release was reviewed. The physician order indicated, Take one tablet by mouth every 4 hours, as needed for lower back pain. LVN 1 stated she did not administer the Oxycodone as prescribed and she should have called the physician to obtain a medication order for Resident 1's generalized pain. During a concurrent interview and record review on 8/20/25 at 10:32 AM with the Director of Nursing (DON), Resident 1's Medication Record, dated July 2025, was reviewed. The Medication Record indicated the pain medication Oxycodone 5 mg immediate release was administered on 10 occasions by multiple nurses for the incorrect indication as follows: 1. 7/16/25 at 3:35 PM - Increased generalized pain2. 7/18/25 at 3 PM - Body pain 3. 7/25/25 at 7 PM - Generalized pain 4. 7/26/25 at 7 AM - Generalized/facial/neck 5. 7/26/25 at 12 PM - Neck pain6. 7/26/25 at 9 PM - Neck pain 7. 7/27/25 at 4:40 AM - Face and Neck pain 8. 7/28/25 at 7 AM - Face Pain9. 7/29/25 at 1 PM - Face and Neck pain 10. 7/31/25 at 8 AM - Neck pain The DON stated the nurses should have obtained a physician order for Resident 1's general pain. During an interview on 8/20/25 at 1:40 PM with Medical Doctor 1 (MD 1), MD 1 stated the nurses can administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain indications even though the indication on his physician order stated for lower back pain. During an interview on 8/20/25 at 1:46 PM with Pharmacist 1 (Pharm 1), Pharm 1 stated it was okay for nurses to administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain reasons other than the indication stated on the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that internal and external medications were stored separately for 2 of 2 medication storage areas observed. This failure had the potential to cause cross-contamination and medication administration errors. Findings: On 04/07/25, at approximately 3:20 p.m., during a tour of the medication storage areas located in the Clamath and [NAME] nursing stations, it was observed that internal-use medications were stored directly adjacent to external-use products without appropriate separation. Specifically, oral medications such as [NAME] & Thrive Loperamide tablets, Glucosamine Sulfate 500 mg capsules, and Calcium Citrate tablets were stored next to external-use items including Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops (Carbamide Peroxide 6.5%). No physical barrier, labeled bin, or designated shelving was in place to distinguish internally administered medications from those intended for external use. During an interview conducted on 04/07/25 at 3:30 p.m. the time of the observation with the facility's Quality Assessment Nurse, he acknowledged the improper storage practice, stating, I didn't know internal and external medications were being stored together, but it looks like we've been doing it that way for a while. This acknowledgment confirmed the storage practice had likely been ongoing and unrecognized by facility staff. The facility's policy, titled Storage of Medications, outlines specific expectations regarding medication segregation. Section 6, subsection B of the policy clearly states, Internally administered medications are kept separate from externally used medications such as lotions, creams, ointments or suppositories. Despite this policy, the observation on 04/07/25 revealed that oral medications, including anti-diarrheals and dietary supplements, were intermixed with external-use medications, such as eye drops and enemas, with no form of separation in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of the Face Sheet, for Resident 9, the Face Sheet, indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses which included depression (feeling sadness) and alzheimer's disease (memory loss). The physician's order, dated 07/29/24, indicated Resident 9 should receive Aripiprazole (Abilify) 2 milligrams (mg) by mouth at bedtime for the treatment of depression. This medication was classified as an antipsychotic and requires monitoring to assess both its effectiveness in managing the targeted condition and the presence of any side effects or adverse reactions. Upon review of the behavior monitoring and side effect tracking tool for Resident 9, the documentation showed that only side effect monitoring was being conducted, such as assessments for drowsiness, dizziness, or extrapyramidal symptoms. There was no documentation of behavioral monitoring, including identification of target behaviors, baseline symptoms, or ongoing evaluations of whether the medication was effective in addressing the resident's depression. In an interview on 04/09/25 at 10 a.m., the Quality Assurance Nurse confirmed that behavioral monitoring had been overlooked and stated, It should have been filled out, but was missed. Based on observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Resident 9 and Resident 19) were free of unnecessary psychotropic medications (drugs that affect brain function, mood, thoughts, or behaviors) when: 1. Staff did not implement non-pharmacological interventions (treatments that do not involve medication prior to administering psychotropic medications) for Resident 19. 2. Staff failed to implement behavioral monitoring related to the use of psychotropic medications for Resident 9. These failures had the potential to result in unecessary drug administration for Residents 9 and 19. Findings: 1. During a review of the Face Sheet for Resident 19, the Face Sheet indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During an interview on 4/9/25 at 8:28 a.m., with Resident 19, Resident 19 stated he notified staff that he was not sleeping well because he experienced jerking episodes throughout the night which had been keeping him awake. Resident 19 stated the physician ordered a sleeping pill. During a review of Resident 19's record on 4/9/25 at 8:35 a.m., the record indicated: On 2/2/24, the physician ordered Melatonin (a supplement used to regulate sleep cycle) at bedtime as needed. On 3/24/25, the physician ordered Temazepam (psychotropic medication-sleeping pill) for insomnia (trouble sleeping) at bedtime as needed. There was no documentation of any non-pharmacological interventions. On 3/24/25, a Nursing Care Plan was developed for Insomnia. Interventions included, Administer Temazepam. There were no non-pharmacological interventions planned to address the resident's insomnia. On 4/1/25, the physician ordered Trazodone (psychotropic medication-sleeping pill) for insomnia at bedtime as needed. There was no documentation of any non-pharmacological interventions. During a concurrent interview and record review on 4/9/25 at 3:16 p.m.,with License Vocational Nurse (LVN) 2, Resident 19's April 2024, Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 19 received Trazodone on 4/1/25, 4/4/25, 4/5/25, 4/6/25, and 4/7/25. There was no documentation which indicated non-pharmacological interventions were attempted prior to administering Trazodone on each date. The MAR further indicated Resident 19 did not receive Melatonin between the dates of 4/1/25 through 4/9/25. LVN 2 stated she did not offer Resident 19 Melatonin prior to administering Trazodone. LVN 2 confirmed there was no documentation in the record which indicated non-pharmacological interventions were attempted prior to administering Trazodone. During a concurrent interview and record review on 4/10/25 at 8:20 a.m., with Director of Nursing (DON), DON stated prior to starting a psychotropic medication, non-pharmacological interventions should have been attempted and documented in the resident's record. Resident 19's March and April 2025 MAR were reviewed with the DON, the DON confirmed there were no non-pharmacological interventions documented prior to administering the psychotropic medications to Resident 19. DON confirmed there was no documentation to show Resident 19 was offered Melatonin to help him sleep in March or April 2025. DON stated Melatonin and non-pharmacological interventions should have been attempted prior to administering psychotropic medication. During a review of the facilities policy and procedure (P&P) titled, Psychotropic Drug Management, SNF, last reviewed 10/21/24, P&P indicated, Resident's care plan will include behavioral interventions implemented in an attempt to decrease the target behaviors . Non-pharmacological, or behavior interventions were attempted, but failed to resolve the cause of the behaviors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-eight opportunities, resulting in an error rate of 10%, and involved two separate insulin administrations and one nasal spray medication for Resident 3. These deviations from proper technique posed a risk for suboptimal therapeutic outcomes. The failure to adhere to manufacturers' instructions for insulin and nasal spray administration not only violates professional standards of practice but also increases the risk of therapeutic failure and resident harm. Findings: 1. According to the manufacture's insert instructions for insulin (#1), the dose button must be held in and the needle kept in the skin for at least five seconds to ensure full dose delivery. Similarly, manufacture's insert instructions for insulin (#2) once the dose button was pressed, the needle should remain under the skin for six seconds. Failing to follow these steps may result in an incomplete dose being delivered. During a review of the Face Sheet for Resident 3, the Face Sheet, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) and muscle weakness. On 4/7/25 at 8 a.m., during medication administration observations, Licensed Vocational Nurse (LVN) 1 was seen administering insulin #1 and insulin #2 to Resident 3. In both instances, the nurse inserted the insulin pen needle and immediately withdrew it after pressing the dose button, without holding the needle in the subcutaneous tissue for the duration specified in each manufacturer's instructions for use. During an interview on 4/7/25 at 8 a.m., at the time of observation, the LVN 1 acknowledged the error and stated, I forgot about holding that insulin needle in the patient as required by the manufacturer. She confirmed that she routinely removed the pen immediately after pressing the dose button and was not consistently following the manufacturer's holding time guidance. 2. According to standard manufacturer's instructions for most Saline Nasal Spray-intranasal sprays, the nasal passages should be cleared (individual should blow their nose) prior to administration to ensure the medication contacts the mucosa effectively. On 4/7/25 at 8 a.m., during medication administration observations, LVN 1 administered a nasal spray to a Resident 3 without instructing the resident to blow their nose beforehand. When interviewed, the LVN 1 stated, I just didn't know that you were supposed to blow the nose for the nasal spray.

Based on observation, leadership interview and dietary department document review the facility failed to ensure sufficient staff were employed as evidenced by the lack of a full-time qualified position to supervise and manage the day-to-day operations of the skilled nursing dietetic services. Failure to ensure sufficiently qualified staff may result in dietetic services that are inconsistent with professional standards of practice placing 35 residents at risk for potential food related medical complications. Findings: Per California Code of Regulations, Title 22, Chapter 3, dietetic services is defined as the provision of safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies. Additionally, California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. The Health and Safety Code describes, in the absence of a full-time Registered Dietitian with supervisory responsibilities for dietetic services, the licensed facility shall employ a full-time qualified dietary services supervisor. There are 7 recognized pathways, all of which are based on a variety of educational experiences. During the initial tour of the main kitchen on 4/7/25, beginning at 8:20 a.m. the surveyor was introduced to the Food Manager (FM). In a concurrent interview, the FM indicated he was responsible for the day-to-day management of both the skilled nursing kitchen, as well as a separately licensed residential care facility for the elderly (RCFE). The FM indicated primary food production activities occurred in the RCFE kitchen with some menu items also produced in the skilled nursing facility (SNF) kitchen. The FM acknowledged his position was not dedicated as full-time to the SNF, rather had foodservice responsibilities for multiple levels of care. The surveyor was also introduced to the Dietetics Assistant Director (DAD), a Registered Dietitian. The DAD indicated her position was responsible for supervisory oversight of the Registered Dietitians as well as the Food Service Managers for both the RCFE, as well as the SNF. The DAD position also included the responsibility of all departmental administrative functions such as staffing and budget. In an interview and concurrent document review on 04/08/25 at 1:30 p.m., with the DAD the organizational chart for the veterans home was reviewed. The DAD indicated the Director of Dietetics position, as well as a food service supervisor (FSS) II position was currently vacant. The DAD indicated that within the current organizational structure there is no position designated to be the full-time qualified Food Service Director dedicated to the skilled nursing facility. The DAD confirmed all of the dietetic services leadership positions within the home are split between the RCFE and the SNF. The DAD acknowledged her position was not dedicated solely to the SNF. The surveyor also reviewed the responsibilities of the Registered Dietitian (RD) within the SNF. The DAD indicated one of the RD positions was dedicated to the SNF, however the position did not include day to day management of dietetic services for the SNF, rather the focus was clinical nutrition care. In an interview on 04/09/25 at 10:15 a.m., the Assistant Administrator (AA) 1 for the home indicated the process for vacancies was to post a position, which was done by Human Resources (HR) in Sacramento. The applications were then forwarded to the departmental supervisor for screening and selection of candidates to interview. The screening then goes back to Sacramento HR for final review who will determine the final candidates eligible for interview. Concurrent review of the Minimum qualifications for the FSS II revealed one of the qualification pathways would be consistent with the regulatory requirements, however there were others that were based solely on experience. The AA 1 indicated he can move positions within an organizational structure at the local level, however position duties would be more difficult to modify and would need to be taken through HR channels. The AA 1 indicated to his knowledge the home had not attempted to make modifications to position descriptions and/or position minimum qualifications. The AA 1 indicated a RD used to be responsible for the day-to-day supervision of the SNF kitchen, however she returned to a clinical nutrition role. Additionally, the AA 1 indicated the home had approved the FM to receive the necessary training as outlined in the California Health and Safety Code. In an interview 04/09/25 at 11:40 a.m., the Registered Dietitian (RD) 1, RD 1 stated she alternates working in the SNF and in the RCFE. The RD 1 stated she does a monthly kitchen inspection at the SNF, completes weekly test trays and helps in the kitchen if they are short staffed. RD 1 indicated she did a monthly sanitation inspection which includes elements such as an evaluation of labeling/dating, food temperatures, observation of staff for hand hygiene and clean up after trayline and temperature testing for food storage. RD 1 acknowledged she does not have supervisory responsibilities for the day-to-day operation of the SNF dietetic services. In an interview on 04/09/25 at 1:10 p.m., the FM stated while he started the coursework to become Certified Dietary Manager, but he has not completed it. Review of the position description for the DAD indicated this position was responsible for assisting in the management of the home's Registered Dietitians and Food and Nutrition operations. The position description for the Food Manager indicated under the direction of Director of Dietetics the position plans, directs and coordinates food service activities. The position description of the Registered Dietitian indicated under the direction of the Director of Dietetics this position completes nutrition assessments and provides medical nutrition therapy. Review of undated, facility policy titled Food & Nutrition Services-Staff Operations and Training (All Homes) documented .Staffing Standards .A. Skilled Nursing (SNF) .2. If a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor will be employed to be responsible for the operation of the food service .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a complete and accurate medical record when consent for the use of psychotropic medication (drugs that affect brain function, mood, thoughts, or behaviors) was not documented in the medical record for one of 12 sampled residents (Resident 19). This failure had the potential for Resident 19 to receive psychotropic medication that the resident did not consent to leading to unwarranted side effects. Findings: During a review of the Face Sheet, for Resident 19, the Face Sheet, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During a concurrent interview and review of Resident 19's record on 4/8/25 at 2:53 p.m., with the Director of Nursing (DON), the following physician's orders were reviewed: On 3/24/25, the physician ordered Temazepam (psychotropic medication used to aid sleep). On 4/1/25, the physician ordered Trazodone (psychotropic medication used to aid sleep). There was no documentation which indicated Resident 19 consented to receive the psychotropic medications. DON stated the ordering physician was responsible discussing the treatment with Resident 19 and for obtaining signed written consent from the resident. DON stated it was important to have written consent in the resident's chart so the medication nurse could verify that Resident 19 consented to receive the psychotropic medication prior to administration of the medication. During an interview on 4/8/25 at 3:37 p.m., with Registered Nurse (RN), RN stated the physician should obtain the Resident's signature on the consent for psychotropic medication form and nursing staff should verify the consent form was signed prior to administering psychotropic medication. RN stated psychotropic medication should not be administered without the resident's consent documented in the record. During a review of Resident 19's Medication Administration Record (MAR), the MAR indicated Resident 19 received Temazepam on 3/24/25, 3/26/25 through 3/31/25, and Trazodone on 4/1/25, 4/4/25 through 4/7/25. During a review of the facility's policy and procedure (P&P) titled, Informed Consent (All Homes), dated 2/28/25, indicated, Written information must include in the written psychotherapeutic drug informed consent . Informed consent will be filed in the Residents' health record . Psychotropic medication therapy informed consent forms will be used by the prescriber to document informed consent for new psychotropic medication orders . The licensed nurse will verify that the Resident's health record contains the documentation that the Resident or resident representative has given informed consent to the proposed treatment or psychotropic drug prior to initiating treatment

Based on observations, dietary and leadership staff interview and departmental document review the facility failed to ensure food handling practices were consistently carried out in accordance with food safety standards when: 1. There were lapses in cooldown monitoring of foods associated with foodborne illness and 2. One staff member was chewing gum during food production activities. These failures had the potential to result in foodborne illness and cross-contamination for the facility's residents. Findings: 1. Potentially Hazardous Foods (PHFs) are those foods capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as meat, beans and canned tuna are considered PHFs and require time/temperature control for food safety during periods of preparation, storage and distribution (US Department of Agriculture [USDA], Food Code, 2022). Cooked foods requiring time/temperature control for safety food shall be cooled: within 2 hours from 135ºF (degrees Fahrenheit) to 70°F and within a total of 6 hours from 135ºF to 41°F or less. Food shall be cooled within 4 hours to 41°F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna (USDA Food Code, 2022). During initial tour observation of the main production kitchen on 04/07/25 beginning at 08:20 a.m., there were multiple pans of frozen entrée foods in Freezer #B. The following foods included, but not limited to, Macaroni and Cheese, dated 2/13/2025 and cooked corned beef, dated 3/15/2025. It was also noted in Refrigerator #A there was approximately one-half gallon of prepared tuna salad, dated 4/6/25. In a concurrent interview the Food Manager (FM) indicated that some of the frozen items were over production and would be used at a later time as a meal substitute. The FM also stated there were various food production methods for the skilled nursing facility (SNF) kitchen. He stated depending on the item and dietary department staffing food items may be prepared in the main kitchen and then transported to the SNF kitchen for distribution, while others may be prepared in the SNF kitchen. During a food production observation on 04/08/25 at 09:20 a.m., the surveyor asked [NAME] (C) 1 to describe the process for preparing tuna salad. C1 indicted the tuna and mayonnaise were stored at room temperatures in the dry storage area. C1, indicated if there was mayonnaise in the refrigerator it would be used first. C1 described the process of mixing the ingredients then placing the finished product in the refrigerator. C1 indicated there was no temperature monitoring during the food storage period, rather temperatures were taken shortly prior to using the tuna. In a concurrent confirming interview with the FM he acknowledged the facility did not monitor food temperatures for items prepared from ingredients at ambient (room) temperature. The surveyor asked C1 to describe the process when there was an overproduction of an item that was intended to be saved for later use. C1 indicated the item would be taken from the hot line and moved to either the refrigerator or freezer and if it did not cool down fast enough, they would utilize the blast chiller (an appliance to quickly cool foods to a low temperature). C1 and the surveyor proceeded to Freezer #B where dietary staff were storing previously cooked items. The following cooked items were present: macaroni and cheese, dated 2/13/25; vegetarian meatloaf, dated 3/16/25 and lentil loaf, dated 3/15/25. Concurrent review of the departmental document titled, Cool Down Log, dated 2/10/25 through 4/7/25 revealed none of the observed items in the freezer were monitored during the cooldown process. In a concurrent interview FM acknowledged there was currently no system to monitor cooldown temperatures for foods prepared from room temperature ingredients. The undated, facility policy titled, Food & Nutrition Services-Leftover and Extra Food (All Homes) guided staff on the process of properly cooling foods, however, did not include guidance for documenting the process. It was also noted the policy did not address the necessity to monitor the cooldown of PHFs from room temperature ingredients. 2. During general food production observations on 4/7/25 beginning at 10:55 a.m., it was noted Food Service Worker (FSW) was preparing mechanically altered items for the noon meal. FSW was consistently moving her mouth in a chewing motion, resembling the motion of chewing gum. During an general conversation with FSW the surveyor noted a white item in her mouth resembling gum. The surveyor asked if she had gum in her mouth to which she stated, I Do. The undated, departmental policy titled, Food & Nutrition-Staff Operations and Training (All Homes) indicated, .Eating/Drinking/Tobacco/Gum in Work Areas . 3. Employees must not chew gum .in kitchen or serving areas .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect 1 of 3 sampled residents (Resident 1) right to personal privacy when Resident 1's bank account statement was opened and viewed by facility staff. This failure resulted in unauthorized access to Resident 1's personal privacy. Findings: During a concurrent observation and interview with Resident 1 on 9/17/2024 at 9:25 AM in the day hall of the facility, Resident 1 was oriented to person and place. Resident 1 stated her son and daughter took care of her finances. During a review of Resident 1's Face Sheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.) Furthermore, Resident 1's Face Sheet indicated the Resident 1's Son had the Durable Power of Attorney. During a review of Resident 1's durable power of attorney, dated 3/1/2023 showed Resident 1's Son's name. During an interview with the Standards and Compliance Coordinator (SCC) on 9/18/2024 at 8:20 AM in the facility's conference room, the SCC stated that the Memory Care staff was authorized to open mail for residents. During an interview with the Medical Social Worker (MSW) on 9/18/2024 at 8:45 AM in the facility's conference room, the MSW stated that she opened and viewed Resident 1's June 2024, Bank Account Statement. MSW stated Resident 1's Son had given his consent to open Resident 1's mail via telephone. The MSW was unable to provide documented evidence to indicate telephone consent was received from Resident 1's Son. During a telephone interview with Resident 1's Son on 9/18/2024 at 11 AM, he denied providing consent to open Resident 1's mail. The facility's policy and procedure titled Mail, Involvement With, Social Services dated 10/20/2023, indicated: The resident or legal representative may request mail assistance on a regular basis. This is especially indicated when a resident is in a coma, physically unable to open the mail, severely demented, blind or paralyzed. Under such circumstances, the mail may be forwarded to their representative or brought to the resident unopened. Mail may only be opened for the member at his or her request. If a resident has a conservator, power or attorney, payee, or other representative, the social worker may forward relevant mail to that representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the plan of care for two of 12 sampled residents (Resident 18 and Resident 25) when: 1. For Resident 18, the care plan intervention Call don't fall signs were not posted, and assistive devices were not within reach. 2. For Resident 25, the care plan intervention Call don't fall signs were not posted, and discontinued assistive devices with signage were present in room. These failures had the potential to result in subsequent falls and serious injuries for Residents 18 and 25. Findings: 1a. During a review of Resident 18's Face Sheet (demographics), the Face Sheet (demographics) indicated Resident 18 was admitted to the facility on [DATE], with diagnoses of left below the knee amputation, right transmetatarsal amputation (surgery to remove part of the foot) and has had frequent falls since admission. During a review of Resident 18's Quarterly MDS, dated [DATE], indicated Resident 18 was able to stand from a sitting position in a chair, wheelchair, or on the side of the bed, as well as transfer to and from a bed to a chair or wheelchair with assistance to set-up or clean-up. Review of Resident 18's BIMS score, indicated Resident 18's cognition was intact. During a review of Resident 18's Care Plan Weekly Summary, dated 4/20/24, Resident 18's Mobility plan of care included, left below knee amputee with prosthesis and able to self-propel manual wheelchair. During an observation on 4/24/24 at 11:02 a.m. in Resident 18's room, Resident 18 was lying in bed while Resident 18's wheelchair was observed across the room and the left prosthetic leg was observed in the bathroom, both not within reach. During a concurrent observation and interview on 4/24/24 at 11:04 a.m. with Quality Assurance Registered Nurse (QARN) in Resident 18's room, QARN stated, I do not know who put his prosthetic in the bathroom or the wheelchair across the room, but both need to be next to him. During an interview on 4/25/24 at 9:31 a.m. with Occupational Therapist (OT), OT stated, Resident is independent for donning and doffing of prosthetic and transfers. OT stated the prosthetic leg and wheelchair should be next to him. 1b. During a review of Resident 18's Fall Care Plan, dated 3/23/24, the Fall Care Plan indicated, Resident 18's interventions included displaying the Call don't fall signs. During an observation on 4/24/24 at 10:02 a.m., in Resident 18's room, there were no Call don't fall signs posted. During a concurrent observation and interview on 4/24/24 at 11:00 a.m., with Quality Assurance Registered Nurse (QARN) in Resident 18's room, QARN stated, I do not see any call don't fall signs posted, there should be three. 2a. During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills and the ability to carry out simple tasks) and other abnormalities of gait and mobility, and ataxic gait (impairment of the ability to coordinate the movements required for normal walking). During a review of Resident 25's Physical Therapy Evaluation, dated 2/13/24, the Physical Therapy Evaluation indicated, .Poor standing balance, fall risk . Gait: Unable . unsafe to ambulate . During a review of Resident 25's Significant Change Care Area Assessment (CAA), dated 3/4/24, the Significant Change CAA indicated, .Falls-CAAs triggered secondary to occasional falls with minor injuries . increased fall risk . for using four-wheel walker (FWW) . During observation on 4/24/24 at 10:22 a.m., in Resident 25's room, there was a sign posted, (Resident name) PLEASE USE YOUR WALKER and a walker was placed to the right side of the signage. During a concurrent interview and record review on 4/25/24 at 9:29 a.m., with Assistant Director of Nursing (ADON), Resident 25's Mobility Plan of Care, dated 4/9/24 was reviewed. The Mobility Plan of Care indicated, . Use of manual wheelchair . The ADON stated walker and signage should have been removed from Resident 25's room. During an interview on 4/25/24 at 9:34 a.m., with Physical Therapist II (PT II), PT II stated, He only uses wheelchair with one person assistance; the walker was discontinued. 2b. During an observation on 4/24/24 at 10:22 a.m., in Resident 25's room, there were no Call don't fall signs posted. During a review of Resident 25's Fall Care Plan, dated 4/9/24, the Fall Care Plan indicated, Resident 25's interventions included displaying of Call don't fall signs. During a concurrent observation and interview on 4/24/24 at 10:55 a.m., with Quality Assurance Registered Nurse (QARN) in Resident 25's room, QARN stated, I do not see any call don't fall signs, and there should be three. QARN stated that the signage was bright yellow with the words Call don't fall. During a review of the facility's policy and procedure (P&P) titled, Care Plans-SNF [skilled nursing facility]/ICF [intermediate care facility] (All Homes), dated 2/13/24, the P&P indicated, . the facility must develop and implement a comprehensive person-centered care plan for each resident . the interdisciplinary team (IDT) will develop and implement comprehensive care plan within 7 days. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment and Prevention Program, dated 10/16/23, the P&P indicated, .the Interdisciplinary Team will develop an individualized plan . to prevent falls to maintain a safe environment for residents . transfer/activity parameters per PT/OT recommendations.

Based on observation, interview, and record review, the facility failed to ensure safe monitoring of pharmaceutical medical supplies when four expired filter needles (a needle designed to remove particles, like glass, that might contaminate medication) were found in the injectable Emergency Drug Kit (E-Kit, small supply of medications for emergency situations). This failure had the potential to result in expired and ineffective medical supplies being used for residents and had the potential to result in contaminated medications being injected into residents. Findings: During an observation on 4/22/24 at 10:29 a.m. in the Klamath Unit medication room, there was a sealed orange box labeled, Klamath E-kit. On the exterior of the E-kit, there was a list of contents, including filter needles, and the date for the earliest upcoming expiration date. The kit contained four filter needles, labeled lot #7025483 (code that identifies one batch of a product that is made at the same time) which did not have any expiration date. During an interview on 4/22/24 at 11:39 a.m. with the Pharmacy Technician (PT), PT stated some filter needles simply did not have any expiration date, but the most recent expiration date was posted on the lid of the E-kit for staff to know when to alert the main pharmacy to replace expired medications and supplies. During an interview on 4/23/24 at 12:06 p.m. with the Director of Nursing (DON), the DON stated she was unsure why there were no expiration dates on the filter needles. During a concurrent observation and interview on 4/24/24 at 9:55 a.m. with Registered Nurse (RN 2) in the Klamath Unit medication room, four filter needles in the emergency injectable medications kit did not have an expiration date. RN 2 stated the filter needles may be used for certain medications stored in the kit, but unable to identify which ones. RN 2 stated he could not find an expiration date for the filter needles. During an interview on 4/24/24 at 10:04 a.m. with PT, PT stated she was able to confirm that the product did not have an expiration date and never will expire by calling the pharmacy. During an interview on 4/24/24 at 11:15 a.m. with the filter needles [brand name] Manufacturer Representative (MR), the MR stated the filter needles associated with lot number #7025483 were produced in January 25, 2017, had a shelf life (time period during which an item may be stored and remain suitable for use) of 1825 days, and expired on January 24, 2022. The MR further stated all their medical supplies have an expiration date. During an interview on 4/24/24 at 2:21 p.m. with the DON, the DON stated the filter needles without expiration date should have been investigated for an expiration date and discarded. During a review of a published study titled, Maximizing patient safety: filter needle use with glass ampules, dated January 2005, the study indicated, Particle contamination of medications obtained from glass ampules can pose serious hazards to patients. Particle contamination may be reduced by using a filter needle when obtaining medication from glass ampules prior to administration. During a review of the facility's policy and procedure (P&P) titled, Emergency Drug Kit, dated 11/27/23, the P&P indicated, The contents are changed as needed depending on the SNF needs and reviewed by the pharmacy services committee. The pharmacist checking the Emergency Drug Kit will also indicate the earliest expiration date and the name of that item on the outside of the container. It is the responsibility of the contract production pharmacy to cycle out the E-kits prior to the expiration date listed on the exterior of the kit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of four sampled residents (Resident 21 and 26) when: 1. A non-crushable medication, pantoprazole (medication to reduce acid production in the stomach), was crushed and administered to Resident 26 despite manufacturer's guidelines not to crush medication due to delayed release. 2. A non-crushable medication, finasteride (medication to treat enlarged prostate), was crushed and administered to Resident 26 despite facility's guidelines regarding handling of finasteride. 3. Resident 21 was not instructed to rinse his mouth after being administered fluticasone furoate (nasal spray used to treat sneezing, itchy or runny nose), umeclidinium (medication used for chronic obstructive pulmonary disease), and vilanterol inhalation powder (a combination of inhaled medications to treat breathing issues) despite manufacturer guidelines to rinse mouth after use to prevent hoarseness and oropharyngeal candidiasis (fungal infection in mouth). These failures resulted in three identified errors out of 27 opportunities for medication administration medications; the facility's medication error rate was 11.11%. Findings: 1. During a review of Resident 26's Face Sheet (demographic), the Face Sheet indicated Resident 26 was admitted on [DATE] with diagnoses of gastroesophageal reflux disease (GERD, disease that causes heartburn), dysphagia (condition that causes swallowing difficulty), and benign prostatic hyperplasia (BPH, condition that causes urination difficulty). During an observation on 4/23/24 at 7:34 a.m. in [NAME] Unit, Licensed Vocational Nurse (LVN 1) was observed crushing pantoprazole, mixing it in applesauce, and administering it to Resident 26. The packaging for the pantoprazole pills was labeled, Do Not Crush. During an interview on 4/23/24 at 9:55 a.m. with LVN 1, LVN 1 stated she was following the physician's order to crush crushable medications. LVN 1 stated that she did not see the Do Not Crush label on the medication blister pack. LVN 1 stated delayed release pantoprazole table was not a crushable medication. During a record review of Resident 26's Physician's Orders, dated 10/18/23, the orders indicated, May crush all crushable medications. During an interview on 4/24/24 at 2:21 p.m. with the Director of Nursing (DON), the DON stated the pantoprazole should not have been crushed. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Altering the form of a medication, including crushing, requires a physician order . long acting or enteric coated dosage forms should not generally be crushed; an alternative form should be sought. During a review of the Prescribing Information (PI) for Pantoprazole, dated May 2012, the PI indicated, Patients should be cautioned that Protonix (pantoprazole) Delayed-Release Tablets and Protonix For Delayed-Release Oral Suspension should not be split, chewed, or crushed. 2. During a review of Resident 26's Face Sheet (demographic), the Face Sheet indicated Resident 26 was admitted on [DATE] with diagnoses of gastroesophageal reflux disease (GERD, disease that causes heartburn), dysphagia (condition that causes swallowing difficulty), and benign prostatic hyperplasia (BPH, condition that causes urination difficulty). During an observation on 4/23/24 at 7:34 a.m. in [NAME] Unit, Licensed Vocational Nurse (LVN 1) was observed crushing finasteride, mixing it in applesauce, and administering it to Resident 26. The packaging for the finasteride pills was labeled, Caution Special Handling. During an interview on 4/23/24 at 9:55 a.m. with LVN 1, LVN 1 stated she was following the physician's order to crush medications. LVN 1 stated that she did not see the Caution Special Handling label on the medication blister pack and was unaware of what that label meant. During an interview on 4/24/24 at 2:21 p.m. with the Director of Nursing (DON), the DON stated the finasteride should not have been crushed. During a record review of Resident 26's Physician's Orders, dated 10/18/23, the orders indicated, May crush all crushable medications. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Altering the form of a medication, including crushing, requires a physician order. During a review of the facility provided document titled, NIOSH (National Institute for Occupational Safety and Health) Hazard Drugs, provided 4/23/24, the document indicated, These drugs require special handling. Use caution when handling these drugs by wearing gloves and do not cut/crush. The document indicated finasteride as one of the drugs that required special handling. 3. During a review of Resident 21's Face Sheet (demographic), the Face Sheet indicated Resident 21 was admitted on [DATE] with diagnosis of mild cognitive impairment. During an observation on 4/23/24 at 8:04 a.m. in Klamath Unit, Registered Nurse (RN 3) was observed administering fluticasone furoate, umeclidinium, and vilanterol inhalation powder with an inhaler to Resident 21 without instructing Resident 21 to rinse his mouth afterwards. The packaging for the inhaled medication included instructions that stated, Rinse your mouth after use. During an interview on 4/23/24 at 10:31 a.m. with RN 3, RN 3 stated Resident 21 did not rinse his mouth after inhaling fluticasone furoate, umeclidinium, and vilanterol inhalation powder, was not advised to rinse his mouth after use, and did not have history of refusing to rinse his mouth after inhaling the medication. RN 3 stated Resident 21 should have rinsed his mouth after receiving a dose of his oral inhaler. During an interview on 4/23/24 at 12:07 p.m. with the Director of Nursing (DON), the DON stated the licensed staff administering fluticasone furoate, umeclidinium, and vilanterol inhalation powder should have coached Resident 21 how to use the inhaler disk, including instructing Resident 21 to rinse and spit after use. During a review of a published study titled, Influence of Mouth Washing Procedures on the Removal of Drug Residues Following Inhalation of Corticosteroids, dated 6/12/06, the study indicated, Mouth washing after inhalation of corticosteroids is effective for prevention of local adverse effects such as hoarseness and oropharyngeal candidiasis. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Medications are administered by legally authorized persons as prescribed in accordance with good nursing principles and practices. During a review of the Full Prescribing Information (PI) for Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol inhalation powder), dated January 2019, the PI indicated, Advise the patient to rinse his/her mouth with water without swallowing following inhalation to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth).

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe, 2. Foods were found uncovered in the storage area, 3. Foods were not labeled appropriately, 4. Unsafe food was not discarded. These failures had the potential to expose residents to food contamination and foodborne illnesses (sickness by consuming contaminated food or drinks) for a population of forty-one residents who consume food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/22/24 at 8:21 a.m. with the Dietetics Assistant Director (DAD) in the main kitchen, a can opener was found with metal chipped off the cutting tip. DAD confirmed, the missing metal part of the can opener and acknowledged the metal was likely flaking into the canned food during use. During a concurrent observation and interview on 4/22/24 at 8:31 a.m. with the Food Manager (FM) in the main kitchen, four out of twelve cutting boards were discolored with deep scratches. FM confirmed, the four cutting boards were overworn and stated bacteria growth could occur in the deep scratches. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated 11/5/23, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair (i.e. free from breaks, corrosion, open seams, cracks, and chipped areas). During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 4-501.12, titled, Cutting Surfaces, dated 1/18/23, indicated, Surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 2. During a concurrent observation and interview on 4/22/24 at 8:28 a.m. with the Food Manager (FM) in the main kitchen, frozen burritos were found in the reach in freezer that were uncovered with ice build-up resembling freezer burn (frozen foods damaged). Also seen in this freezer were three chicken breasts and three vegetable patties in uncovered steam table pans that had ice covering the visible surfaces. FM stated, It should be covered. During an observation on 4/22/24 at 8:30 a.m. in the main kitchen, a bag of pork was left open to the air in the walk-in freezer. A steam table pan containing vegetarian chicken and two large pans of uncooked ravioli were uncovered in the walk-in freezer. During an interview on 4/24/24 at 2:30 p.m. with the Dietetics Assistant Director (DAD), DAD stated items are to be covered during storage to prevent cross contamination as well as to maintain food quality. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 3-302.11, titled Packaged and Unpackaged Food - Separation, Packaging, and Segregation, dated 1/18/23, indicated, FOOD shall be protected from cross contamination by: . storing the food in packages, covered containers, or wrapping. 3. During a concurrent observation and interview on 4/22/24 at 8:28 a.m. with the Food Manager (FM) in the main kitchen, a large plastic container of black pepper and a large plastic container of whole bay leaves had black labeling on top of the black surface. FM confirmed, staff would not be able to visualize the use-by date on these items. During an observation on 4/22/24 at 10:29 a.m., in the reach-in freezer for the satellite (Skilled Nursing) kitchen, eight out of nine ice cream bowls did not have a label. During an interview on 4/24/24 at 2:35 p.m. with the Dietetics Assistant Director (DAD), DAD stated staff were expected to label food items with a used-by date. DAD further stated, staff were expected to check the use-by date in order to ensure food products were served before they became unsafe to eat. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services - Leftover and Extra Food, dated 11/5/23, the P&P indicated, Labeling, dating, and monitoring refrigerated food, including but not limited to, leftovers, so it is used by its used-by date or frozen were applicable or discarded. 4. During a concurrent observation and interview on 4/22/24 at 8:28 a.m. with the Food Manager (FM) in the main kitchen, two apple juice boxes were labeled with an opened date of 4/4/23 and a received date of 4/5/24. FM stated they seemed to be mismarked which could be confusing to staff regarding the products safety. One apple juice box was shown with a manufacturer expiration date of 4/16/24. FM confirmed, the apple juice box was expired and discarded it. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Storage Procedure Guidelines (All Homes), dated 1/2/24, the P&P indicated, A. Expiration dates printed by the manufacturer apply until the product is opened. B. Once opened, use the manufacturer's stated time limits.

Based on observation, interview, and record review the facility failed to ensure that two out of eight dumpsters were covered for the main and the satellite kitchens. This failure had the potential to attract pests, rodents and spreading bacteria and leading to food contamination for a population of forty-one residents. Findings: During a concurrent observation and interview on 4/22/24 at 9:05 a.m., with the Assistant Administrator (Admin 2), one out of four trash dumpsters for the main kitchen was not covered, exposing trash. Admin 2 confirmed, it should be closed and proceeded to close the two lids. During an observation on 4/23/24 at 10:56 a.m., in the satellite kitchen, one out of four trash dumpsters was not covered, exposing trash. During an interview on 4/24/24 at 2:30 p.m., with the Dietetics Assistant Director (DAD), DAD stated, trash dumpsters need to be closed at all times when not in use, because it can attract rodents or pests to the facility. During a review of the facility's policy and procedure (P&P) titled, Waste Management Program, dated 12/12/23, the P&P indicated, Movable bins, when used for storing or transporting solid wastes from the premises, will have tightfitting covers and be closed when not being loaded.

Based on interview and record review, the facility failed to protect Resident 1 from verbal abuse when CNA 1 (certified nurse ' s assistant 1) called Resident 1, you d**k, after Resident 1 punched CNA 1 on the chest. This failure resulted in verbal abuse to Resident 1. Findings: During an interview on 12/22/23 at 7:00 p.m. with CNA 3, CNA 3 stated, CNA 1 was assigned to Resident 1 ' s room. CNA 3 continued, CNA 2 and CNA 3 heard a call light ring, and they went to check who was calling. CNA 3 added they saw the light was from Resident 1 ' s room, and she started to walk to Resident 1 ' s room when CNA 2 joined. CNA 3 stated that as she was approaching Resident 1 ' s room, she heard a commotion in the room, so she listened at the door. CNA 3 added, she heard Resident 1 fussing and fighting, then she heard CNA 1 yell, F***ing D**k, to which CNA 2 told CNA 3 that was inappropriate. CNA 3 stated CNA 1 went to get linen for Resident 1 ' s room and CNA 2 and CNA 3 asked CNA 1 to leave the room. CNA 3 added she and CNA 3 took over care for Resident 1 and CNA 1 stayed outside the door. CNA 3 stated, she reported the incident to Charge Nurse 1, who notified SRN 1 (Supervising Registered Nurse 1). During a subsequent interview on 12/29/23 at 6:20 p.m. with CNA 3, CNA 3 stated, I miss interpreted my words. (CNA 1) did not use the F word. (CNA 1) just said ' you d**k ' to (Resident 1). During an interview on 12/22/23 at 7:30 p.m. with CNA 2, CNA 2 stated Resident 1 was on the memory care unit. CNA 2 added, she and CNA 3 heard a call light ring and checked to see whose call light it was. CNA 2 continued, she saw that it was for Resident 1, who could be combative and refused care. CNA 2 stated, I understand when a Resident becomes combative and refuses care, we are supposed to stop our care and come back in 5-10 minutes. CNA 2 stated, CNA 1 had pushed the call light for help and Charge Nurse 1 asked for CNA 2 to help CNA 1. CNA 2 stated that she arrived at Resident 1 ' s room prior to CNA 3 and Resident 1 was being combative. CNA 2 continued, she was trying to help Resident 1 in his bed when Resident 1 punched CNA 1 on the chest, and CNA 1 responded, stop that you dick. CNA 2 added, CNA 3 entered the room and kicked CNA 1 out of the room. During a record review of the MDS (Minimum Data Set) for Resident 1, dated 8/21/23, the record showed a BIMS (Brief Interview for Mental Status) score of 3 in a range of 0-15. A higher BIMS score indicated a intact cognitive response and a lower BIMS score suggested cognitive impairment. During a review of the Behavior Care Plan for Resident 1, the plan documented under the problem list, physical aggression towards others on 8/28/23 and striking out at staff on 11/18/23. The plan showed the interventions of provide redirection as indicated on 8/25/22, redirect and keep distance on 12/12/22, and avoid confrontation, monitor mood on 11/18/23. During a review of the Physicians Assessment, for Resident 1 dated 9/14/23, the assessment showed under A/P (assessment-plan), 1. Lewy Body Dementia (disease associated with abnormal deposits of a protein called alpha-synuclein in the brain).

Based on interview and record review, the facility failed to report an alleged abuse incident to law enforcement officials when Resident 1 reported a sexual assault incident in the Skilled Nursing Facility. This failure did not allow for law enforcement officials to conduct an investigation. Findings: During an interview on 9/13/23 at 11:22 p.m. with Standards Compliance 1 (SC 1), SC 1 stated when referring to the section of the policy titled, Will report to in accordance with State law, SC 1 stated We reported to the Ombudsman (resident advocate) and CDPH (California Department of Public Health) Licensing (oversight and monitoring agency for California skilled nursing facilities). SC 1 added, If we found an assault had occurred, we would have reported it to California Highway Patrol (CHP). SC 1 said, Our CHP doesn't want everything reported to them, only the financial and serious injuries. SC 1 stated after Social Worker 1 (SW 1) and SC 1 spoke to the Resident 1, SC 1 stated, We determined he wanted to shower himself. He does not want males to shower him. SC 1 added, The more Resident 1 talked about the assault, the assault became less intense, and he wanted to be given choices so he could make his own decisions. SC 1 stated, Resident 1 did not want male staff to assist him with showers, he preferred female staff only. SC 1 added, Resident 1 reported to the doctor, his mind was all befuddled because Resident 1 did not remember seeing the doctor yesterday. During an interview on 9/13/23 at 1:20 p.m. with California Highway Patrol officer 1 (CHP 1), CHP 1 stated, We encourage them (facility) to report even if it (the crime) is farfetched for their facility. That (the crime) is for us (CHP) to determine, not the facility. The facility handles the administration duties and we (CHP) handle the investigations. During a review of the facility's policy and procedure titled, Elder Abuse, Prevention and Reporting, last reviewed 6/8/23, the policy indicated under reporting, The home administrator or designee will report to officials in accordance with State law, including to the State Agency and Adult Protective Services where state law provides for jurisdiction in long-term facilities. The policy continued, All alleged violations will be reported immediately, but no later than two hours-if the alleged violation involves abuse or results in serious bodily injury. The policy added, Reporting the results of all investigations to the Administrator or his or her designated representative and to other officials, in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate action must be taken.

Based on interview and record review, the facility failed to follow their Policy and Procedures (P&P) on abuse reporting for two of two sampled residents (Resident 1 and Resident 2), when an abuse allegation was made by a Custodian Worker (CW 1). This failure had the potential of putting residents at risk for harm by not following proper procedures including removing the alleged abuser from patient care, failing to complete proper documentation, and notifying the appropriate agencies. Findings: During an interview on 8/29/23 at 7:15 a.m., with CW 1, CW 1 stated on August 19, 2023, at 08:10 a.m. a Certified Nursing Assistant (CNA 1) was in Resident 1 room and heard the Resident yell at her to get out of his room. CNA refused to leave and forced Resident 1 into his wheelchair to take him to the breakfast area. CW 1 stated CNA 1 then could be heard and seen by everyone verbally agitated and picking on the resident and stated, You are a nasty mean old man to which he replied, No I'm not, go away. CW 1 stated Resident 1 asked CNA 1 to go away multiple times and she just stood there and made rude comments. CW 1 observed CNA 1 approach Resident 2, who was already agitated, and she kept giving him a giant, belittling, mocking/sneer smile to agitate him even more. The nurses attempted to redirect Resident 2, but CNA 1 continued to follow him and get into his face. CW 1 stated Resident 2 was so upset he used his walker to try and hit everyone and everything. During an interview on 8/29/23 at 9:30 a.m., with CW 1, CW 1 stated he did not complete SOC 341 (Report of Suspected Dependent Adult / Elder Abuse). CW 1 stated he called and reported to his supervisor regarding the incident on 8/19/23. CW 1 stated he wasn't aware if his supervisor completed form SOC 341. CW 1 stated he should have followed facility P&P for abuse reporting. During an interview on 8/29/23 at 9:40 a.m., with Custodian Supervisor (CS 1), CS 1 stated on 8/19/23, he received a phone call from CW 1. CS 1 stated CW 1 had some concerns regarding inappropriate behavior from CNA 1 to residents. CS 1 stated he informed CW 1 that if he felt and witnessed elder abuse, he was a mandated reporter. CS 1 stated he advised CW 1 to talk with Nursing Supervisor and make a call to the Ombudsman (an independent official person who investigates complaints against the facility). CS 1 stated he did not instruct CW 1 to complete SOC 341. CS 1 stated he should have instructed CW 1 to complete SOC 341, but he completely forgot. CS 1 stated they did not follow facility P&P. During an interview on 8/29/23 at 9:45 a.m., and 11:00 a.m., with Standards Compliance Coordinator (SCC 1), SCC 1 stated CW 1 did not inform her that he felt the residents had been abused or neglected. SCC 1 stated CW 1 did not inform the Supervising Registered Nurse (SRN), and he should have followed through to ensure proper reporting was completed. SCC 1 stated CW 1 did not complete SOC 341 which delayed the internal investigation initiation which began on 8/21/23. SCC 1 stated, on 8/19/23 and during the facility investigation, residents were not protected from potential harm by removing the accused from any patient contact. SCC 1 stated they did not follow facility abuse P&P. SCC 1 stated CNA 1 was not removed from patient care on 8/19/23 and during the ensuing investigation. SCC 1 further stated they (the facility) did not report the abuse allegation to California Department Public Health (CDPH). During a review of Resident 1's and Resident 2's Investigation Report (IR), dated 8/24/23, the IR indicated, Custodian [CW 1] sent an email on August 19, 2023 regarding CNA [CNA 1]. [CW 1] alleges that [CNA 1] refused to leave resident [Resident 1] room when he yelled at her to Get the hell out of my room . [CW 1] further alleges that CNA [CNA 1] forced resident [Resident 1] into his wheelchair and called him names. [CW 1] said [Resident 1] looked neglected (hair messy and dirty). [CW 1] went on to talk about a different incident that CNA [CNA 1] was involved in, [CW 1] alleges that Resident [Resident 2] was already agitated by CNA [CNA 1] and [CNA 1] kept giving [Resident 2] a giant belittling mocking/sneer smile to agitate him even more. [Resident 2] went on ramming everyone and everything with his walker . The facility P&P titled, Elder Abuse, Prevention and Reporting dated 6/4/20 indicated, .Each Resident has the right be free from abuse, exploitation, mistreatment, neglect, and misappropriation of property . D. Employee procedure / response for situation, allegations, and suspicions of elder abuse. 1. If employee witness, suspects, or is told of an incident of abuse, or identifies injury of unknown origin that is of suspicious nature, the employee will immediately: a. Protect the Resident from harm, including separating the Resident from the alleged abuser; b. Nursing staff will conduct physical and psychosocial assessments, as appropriate, and make necessary care plan revision and referrals for follow up; c. Ask for security and / or supervisor assistance to ensure safety; d. Protect Residents from harm during an investigation; e. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; f. The home will implement interventions to keep alleged abusers from unsupervised Resident access during any investigations related to the incident. IV. Reporting. The mandated reporters is required to complete the Elder Abuse Mandated Reporter form (SOC 341), and report the incident to the Supervisor so that appropriate protection of the Resident can be initiated. All witnessed /alleged violations will be reported immediately to the appropriate authorities .

Based on interview and record review, the facility failed to provide transportation to a medical appointment for one of 14 sampled residents (Resident 26). As a result of this failure, Resident 26 missed his scheduled medical appointment, and his care was delayed. Findings: During an interview with Resident 26 on 5/1/23 at 11:16 a.m., Resident 26 stated he had pain in his right eye and had ongoing issues with dry and irritated eyes. Resident 26 stated he had a scheduled optometry (eye doctor) appointment on 4/25/23, but he was unable to attend because the facility did not have staff available to escort him. Resident 26 reported that his appointment was rescheduled for 9/18/23 (over four months later) and he could not get an earlier appointment. During an interview with the Office Technician (OT 1) on 5/2/23 at 3:12 p.m., OT 1 stated Resident 26 had an appointment on 4/25/23 with his eye doctor but it was canceled because there was not a Registered Nurse (RN) available to accompany him. OT 1 stated there was a medical transport service the facility used for residents who have medical needs, but she was unsure of the process for scheduling. OT 1 stated Resident 26's appointment was rescheduled for 9/18/23, which was the earliest available appointment. During an interview with the Director of Nursing (DON 1) on 5/4/23 at 9:20 a.m., DON 1 stated Resident 26 needed a RN to accompany him to his medical appointments because he was on oxygen. DON 1 stated there was a procedure for scheduling RN transports posted at the nursing station and confirmed the procedure was not followed. Review of Resident 26's plan of care titled Visual Function, initiated on 12/8/21, indicated Resident 26's problem list included, Alteration in Visual Function related to dry eyes. Goals included, No complaints of dry eyes. Interventions included, Administration of eye drops and optometry appointments. Review of the medical transport instructions posted at the nursing station titled, Care-a Van directed staff to call the transport service with approval from the charge nurse and email the residents' appointment information to the service. The facility did not provide a policy related to scheduling transportation for resident appointments during the survey.

Based on observation, interview, and record review, the facility failed to provide food that was palatable (refers to the taste and/or flavor of the food) and attractive (refers to the appearance of the food when served to residents) to one of 12 sampled residents (Resident 10). These failures had the potential to result in decreased resident meal intakes, negative impact on resident's nutritional status, and a negative impact on resident's overall health and quality of life. Findings: During an interview on 5/1/23 at 10:10 a.m., Resident 10 complained about the quality of the food provided by the facility and stated, The food does not taste good. During an observation and interview on 5/1/23 at 11:38 a.m. in Resident 10's room, Resident 10 was observed sitting and picking at his lunch. Resident 10 voiced his complaints about the cottage cheese being watery and that his grilled ham and cheese sandwich was burnt. It was observed that the cottage cheese was watery, and the grilled ham and cheese was burnt (the bread had a blackened appearance on both sides). Resident 10 had not eaten any of the cottage cheese and only ate a few bites of the grilled ham and cheese sandwich. When asked if Resident 10 had notified staff about the food quality, Resident 10 stated, I have, and sometimes they will replace the food, but the food quality is still the same. During an interview on 5/3/23 at 1:23 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated that Resident 10 frequently complained about the quality of the food and did not usually request replacement meals. When asked what staff did to ensure Resident 10 was eating and getting adequate nutrition, CNA1 stated, Resident 10 goes to the general store and buys snacks, such as chips and cookies, so he is eating. When asked if the resident complained about his lunch on this specific day, CNA1 stated Resident 10 requested the soup for lunch and then he complained about it. No alternatives were offered to the resident. During an interview with Resident 10 on 5/3/23 at 1:28 p.m. Resident 10 stated he was unhappy because the soup did not taste good and he did not eat it. When asked if he let staff know about the soup not tasting good, Resident 10 stated he had stopped letting staff know because they never addressed the problem. Resident 10 stated he would get the same type of food quality again, so it was not worth it. During an interview on 5/3/23 at 1:52 p.m. with the [NAME] Supervisor (Cook S1), he stated that they usually do not get many complaints about the quality of residents' food. When asked what the process is if a resident does complain, [NAME] S1 stated that they would remake the meal for the resident. When asked how a grilled cheese sandwich is usually cooked, [NAME] S1 stated, The expectation is that the sandwich will be grilled to a toasty light brown color and should not appear burnt. When asked about the normal consistency of cottage cheese that is served to residents, [NAME] S1 stated, The expectation is, it should not be watery or runny, it should mound. During a review of facility policy and procedure titled Food and Nutrition - General Regulations (All Homes) last reviewed on 5/18/22 indicated, I. A. Food and Nutrition Services will provide food of the quality and quantity to meet each Resident's needs in accordance with the physician's orders . I. D. Resident's food preferences will be adhered to as much as possible . IV. A. Recipes for all items that are prepared for regular and therapeutic diets will be .used to prepare attractive and palatable meals, in which nutritive values, flavor and appearance are maintained . IV. B. Food will be served attractively, at appropriate temperatures, with appropriate eating utensils in a form to meet individual needs.

Based on observation, interview, and record review the facility failed to ensure resident's personal food items were labeled and dated, and the facility was unable to provide evidence of nursing staff training and competency regarding food safety and sanitation requirements in nursing unit kitchenettes. These failures had the potential to result in foodborne illness for residents consuming food from the nursing unit kitchenettes. Findings: Review of a document titled Food & Nutrition Services - Outside Food for Residents 7265 v.2, review date 5/23/22, showed It is essential that any food brought in and served to residents is safe to consume and does not increase the risk of foodborne illness, conflict with dietary restrictions, allergies, sensitivities or increase the risk of choking or aspiration and that food or beverages brought by the resident, family or visitors for resident's use will be labeled with the resident's name and the date the item was stored. During an observation on the memory unit on 5/1/23 at 3:00 pm, the resident food kitchenette was not sanitary (Cross Reference F812). Certified Nursing Assistant A (CNA A) was emptying resident water pitchers into kitchen sink. The refrigerator and freezer were full of food and beverages from the facility and from outside the facility. Only food provided by the facility was labeled and dated. The counter was piled with additional boxes of sodas, cereal bars, popcorn and other resident food. A cabinet held an unlabeled, undated bag of candy. In a concurrent interview, CNA A identified popsicles, food and beverages in the refrigerator, the freezer and on the counter as belonging to one of their residents and confirmed they were not labeled or dated. When asked how staff would know who the items belonged to, CNA A stated staff would ask a co-worker, and that staff updated each other with information during report/team meeting. In an additional concurrent interview, the Quality Assurance Nurse (QAN) stated the expectation in the resident kitchenette was that the facility's kitchen stocked the refrigerator. He stated food brought in from the outside was supposed to be labeled with the resident's name, and if foods and beverages were not labeled with the resident's name, they could be fair game for anyone to consume. During an interview with the Administrator (ADMIN) on 5/4/23 at 11:00 am she stated they did not have any evidence of training and competency for nursing staff regarding their responsibilities in the nursing unit kitchenettes and working with resident food (food safety, sanitation, cleaning ice machine, dishwasher use and temperature monitoring).

Based on observation, interview, and record review the facility failed to ensure pureed foods provided to residents were of proper consistency when they were not smooth and spread thinly across the plate. These failures had the potential to cause difficulty swallowing for some residents, to look unappetizing and be difficult to self-feed for some residents, and to result in decreased meal intakes and nutritional status. Findings: During an observation in the cook's area on 5/2/23 at 10:35 a.m., [NAME] A pureed ham. In a concurrent interview she stated it was just ham with no pineapple because pineapple would not get smooth. She added milk to the ham puree and then stated she added 2 oz. gravy per serving. [NAME] A stated pureed food needed to be smooth and to mound together, with pudding-like consistency. The meal's spinach, beans, cornbread and strawberries and cream were not pureed until later and the process was not observed. A test tray study including a regular lunch tray and a pureed lunch tray was conducted on 5/4/23 at 11:45 a.m. after the last resident lunch meal was served. In a concurrent observation and interview, the Food Service Director (FSD) took the temperature of the foods with a facility thermometer and then the appearance of the meal, the flavor and consistency was evaluated. During evaluation of the pureed tray, the FSD noted the ham was nicely mounded but grainy and salty. The spinach, beans, and cornbread were thin and spread across the plate and the FSD stated The other pureed foods should be standing up. She described the strawberries with cream as almost watery thin .way too thin. Review of recipes provided by the FSD titled Pureed Ham Glazed with Pineapple, Pureed Beans Seasoned, Pureed Spinach Sauteed w/Garlic (fresh), Pureed Cornbread (scr), and Pureed Strawberries & Cream (fzn) all showed these instructions: Measure desired number of servings in food processor. Blend until smooth. Add (pineapple juice, gravy or broth, water, milk, cream depending on product) if product needs thinning. Add commercial thickener if product needs thickening. Review of the facility specific diet manual showed it was approved and signed by the Registered Dietitians on 3/13/23. It's description of the Regular Pureed Diet was The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft and smooth state such as pudding. Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve the appropriate consistency.

Based on observation, interview, and record review the facility failed to ensure qualified leadership staff when 1. There was no qualified, dedicated full time staff to oversee food services for the Skilled Nursing Facility (SNF) kitchen and residents since at least November 2022. 2. The department was short staffed by 23 out of 65 budgeted positions, including eight leadership/supervisorial positions, and no food service manager since November 2022, resulting in closure of the SNF kitchen. 3. There was not an adequate or effective system in place to ensure that position-specific staff training and competency in skills and knowledge essential for food safety and sanitation occurred. These failures had the potential to result in foodborne illness, and to negatively affect overall health for residents living in the facility. Findings: Review of an undated document titled Duty Statement, Class: Dietetics Director showed the Food Services Director (FSD) was responsible for the day-to-day operation of the Food and Nutrition Services Department. Essential functions included coordinate recruitment, selection interviews and hiring of department staff, provide training and in-services to staff, and conduct management sanitation rounds. 1. There was no qualified, dedicated full time staff to oversee food services for the Skilled Nursing Facility (SNF) kitchen and residents since November 2022. Review of California Health and Safety Code 1265.4 showed (a) 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 full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. During an interview with the FSD on 5/3/23 at 11:52 a.m. she stated they had not had a Food Service Manager since 11/5/22. When asked what was being done for recruitment, she stated they were working on hiring an office technician first as that position was key. Then they would start to work on hiring a Food Service Manager. When asked how the responsibilities of the position were being covered, the FSD stated she, the cook supervisors, and the food service supervisor worked together and did their best. She stated none of the supervisors had Dietary Services Supervisor or Certified Dietary Manager credentials, but they all had years of experience. 2. The department was short staffed by 23 out of 65 budgeted positions, including eight leadership/supervisorial positions, and no food service manager since November 2022, resulting in closure of the SNF kitchen. Review of Title 22 §72103 showed dietary (Food and Nutrition Services) is a required service in skilled nursing facilities. During an interview with the Food Service Director (FSD) on 5/1/23 at 11:32 a.m. she stated she was a Registered Dietitian (RD) and had worked there for about a year and a half. She stated she had responsibility over all food services as well as the clinical dietitians. The FSD shared their department's staffing was down by about 1/3, due to the COVID-19 pandemic, some retirements, and from staff finding other opportunities for advancement. The department currently had 42 staff but was budgeted for 65 staff, and they currently did not have a Food Service Manager nor an Office Technician (clerical staff). Review of an organizational chart titled Kitchen/Dietetic Counseling/ Food Services, dated May 2, 2023, and signed by the Administrator 12/31/22, showed seven out of 12 leadership/ supervisorial positions in the Food and Nutrition Services Department (FANS) were vacant, including the Office Technician position, a SNF Administrator, a Dietetics Assistant Director, a Food Manager, a Food Service Supervisor II, and two Food Service Supervisors I. During an interview with Registered Dietitian A (RD A), RD B, and RD C on 5/3/23 at 11:21 a.m. they stated their roles in the kitchen involved communication about residents care, creating resident tray tickets including food preferences, conducting test trays. RD B stated We were hired as clinical dietitians. RD A stated they also assisted with the Office Technician position duties since that position was vacant. They also helped with the menus and nutrient analysis. During an interview with the Food Service Director (FSD) on 5/3/23 at 11:52 a.m. she stated their staffing shortage resulted in the closure of the facility's Skilled Nursing Facility kitchen, so the SNF resident's meals were being served from the RCFE (Resident Care Facility for the Elderly) communal living kitchen. While RCFE residents had returned to eating together in the communal dining room, the SNF residents continued to eat their meals in their rooms. 3. There was not an adequate or effective system in place to ensure that position-specific staff training and competency in skills and knowledge essential for food safety and sanitation occurred (Cross Reference F802, F805, F812). Review of a document titled Food & Nutrition Services - Staff Operations and Training (All Homes) 6325 v.5, dated 4/11/23 showed The Food & Nutrition Services Department will provide sufficient staff to be employed, oriented and trained .Department staff will be trained on and will follow sanitation and infection prevention procedures for the health and safety of Residents at the home .Food & Nutrition Services personnel will be trained in basic food safety and sanitation techniques, prevention of foodborne illness, wear clean clothing, and a cap or hair net .Orientation and in-service training is provided at time of employment and as needed. In-service training sessions are performed by qualified, assigned personnel .Employees will follow the hand wash policy and procedure of the Home and use gloves as appropriate. During multiple observations in the kitchen beginning 5/1/23 at 9:05 a.m., staff hair was not adequately restrained, staff did not change their gloves and wash their hands when changing tasks, multiple pieces of equipment were not clean (can opener and mount, ovens, floor drains, and the ice machine), and staff did not clean fixed equipment according to professional standards of practice, and did not follow manufacturer's instructions for use of quat (quaternary ammonia) sanitizer (Cross Reference F802, F812). During an observation of test trays and concurrent interview with the FSD on 5/2/23 at 11:45 a.m. pureed ham was grainy when it was required to be smooth, and spinach, beans, cornbread and strawberries and cream spread across the dish when they wee supposed to mound with a pudding-like consistency. (Cross Reference F805). During and observation and concurrent interview with FST 2B on 5/3/23 at 7:48 a.m. he showed how he cleaned the kitchen ice machine when assigned by supervisors to do it. The ice machine was not sanitary and a white paper towel wiped across a white tube and also below the cuber returned a black substance resembling mold. Instructions for cleaning posted on the ice machine by Food and Nutrition Services did not match the manufacturer's instructions. During an interview with the Administrator on 5/4/23 at 9:20 a.m. she stated the facility did not have any position-specific training and competency documents for FST 2B. There was no evidence FST 2B had been trained and was competent to clean the ice machine. During an interview with the Food Service Director (FSD) on 5/1/23 at 11:32 a.m. she stated that after facility general orientation new staff were trained into their positions by supervisors and other staff, first observing, then helping, then working on their own. She stated staff in-services had not been done through the pandemic, and they had their first in-service since the pandemic the previous month, on therapeutic diets. On 5/4/23 at 8:20 a.m., training and competency documents were requested for the following staff: Food Service Technician 1-C (FST C), FST E, Food Service Technician II-A (FST 2A), FST 2B, Food Services Supervisor A (FSS A), [NAME] A, [NAME] Supervisor 1 (Cook S1), and [NAME] S2. A review of the staff training and competency documents provided on 5/4/23 at 9:15 a.m. showed Food and Nutrition Services staff FST C, FST E, FST 2A, FST 2B, FSS A, [NAME] A, [NAME] S1, and [NAME] S2 completed the facility's initial, general, New Employee Orientation Checklist used for every staff hired in facility. An additional computer-generated list titled Course Completion History for each staff showed courses were completed on topics such as neglect, abuse, personal protective equipment, fire safety, first aid and ergonomics. Further review showed this training regarding staff: FST C - Three of 181 training events dated 3/2015 to current included FANS position specific topics FST E - Five of 205 training events dated 1/2015 to current included FANS position specific topics FST 2A - Six of 182 training events dated 7/2016 to current included FANS position specific topics FST 2B - Three of 155 training events dated 1/2015 to current included FANS position specific topics FSS A - Five of 143 training events dated 7/2016 to current included FANS position specific topics Cook A - Two of 91 training events dated 6/2020 to current included FANS position specific topics Cook S1 - Six of 220 training events dated 3/2015 to current included FANS position specific topics Cook S2 - Two of 290 training events dated 5/2016 to current included FANS position specific topics During an interview with the Administrator (ADMIN) on 5/4/23 at 9:20 a.m. she stated that for food services they only had position specific training and competency checklists for one Food Service Supervisor A (FSS A), and one for [NAME] Specialist A (Cook A). The facility did not have position specific training and competency checklists in place for any of the remaining six Food and Nutrition Staff records requested.

Based on observation, interview, and record review the facility failed to ensure an adequate number of staff with the necessary skills to carry out the functions of the department when 1. The Food and Nutrition Services department had inadequate staffing. 2. There was no evidence that position-specific staff training and competencies were routinely in place to ensure food safety and sanitation in the kitchen and A. Staff did not adequately restrain their hair B. Staff did not wash hands and change gloves between tasks C. Equipment was not sanitary D. Equipment was not cleaned per professional standards of practice E. The ice machine was sanitary F. Foods were not pureed to the proper consistency These failures had the potential to result in foodborne illness and to impact the nutritional status of residents living in the facility. Findings: Review of a document titled Food & Nutrition Services - Staff Operations and Training (All Homes) 6325 v.5, dated 4/11/23 showed The Food & Nutrition Services Department will provide sufficient staff to be employed, oriented and trained .Department staff will be trained on and will follow sanitation and infection prevention procedures for the health and safety of Residents at the home .Food & Nutrition Services personnel will be trained in basic food safety and sanitation techniques, prevention of foodborne illness, wear clean clothing, and a cap or hair net .Orientation and in-service training is provided at time of employment and as needed. In-service training sessions are performed by qualified, assigned personnel .Employees will follow the hand wash policy and procedure of the Home and use gloves as appropriate. Review of undated documents titled Duty Statement, [facility] for various positions showed position responsibilities included: Food Service Technician I - serves and assists with the preparation of food and beverages, cleans and maintains food service equipment, utensils, and work areas as required. Safely operate, clean, sanitize and maintain food service equipment; Assist in food service and related work .follow department guidelines and procedures for the proper handling and storage of food and supplies. Attend meetings and required in-service training classes. Food Service Technician II - Leads, instructs, and works with employees in serving or assisting with the preparation of food and beverages; cleans and maintains food service equipment, utensils, and work areas. Act as lead foodservice worker .maintain uniform food-handling practices and standards of safety and sanitation. Attend meetings and required in-service training classes. Food Service Supervisor 1 - Coordinates the work of staff in serving food; cleanliness and maintenance of work areas, equipment and utensils. Provide leadership and direction to food service staff .Select and train staff .Maintain uniform food handling practices .Follow department guidelines and procedures for the proper handling and storage of food and supplies. Ensure required monthly training is completed. Cook Specialist 1 - Assists with the preparation, cooking, and dispensing of a variety of food following standardized recipes and methods of preparation. Works with food service staff. Cleans and maintains culinary utensils, equipment and work areas. Instruct and lead staff in food service and cleaning procedures. Attend in-service training classes and regular monthly staff meetings. Comply with all applicable local, state and federal food handling and food safety regulations. Supervising [NAME] 1 - Supervises cooks and food service staff and assists with the preparation, cooking and service of food. Prepares, cooks and dispenses food and serves as lead cook. Supervise and assist in the maintenance of culinary utensils and equipment and the cleaning of various storage and work areas. Conduct inspections and maintain safe food handling practices and standards for safety and sanitation. Comply with all local, state, and federal regulations. Attend meetings. Attend required in-service training. 1. The Food and Nutrition Services (FANS) Department had inadequate staffing During an interview with the Food Service Director (FSD) on 5/1/23 at 11:32 a.m. she stated their staffing was down by about 1/3 since the COVID-19 pandemic, and with some retirements, and from staff finding other opportunities for advancement. They currently had 42 out of 65 budgeted staff. FSD stated the staffing shortage caused the facility to close the skilled nursing unit's (SNF) kitchen, to serve all SNF and communal living residents from the communal living kitchen, and for SNF residents to dine in their rooms instead of a dining room. Review of the staff schedule for May 2023 showed 21 vacant positions including a food service manager, office technician, three food service supervisors, and 16 other positions. During further interview with the FSD on 5/3/23 at 11:52 a.m. she was asked about her efforts for staff recruitment. She stated they were working on getting an office technician first as that was a key position, then would work on filling the Assistant Food Manager position. She stated there had been no Food Service Manager since November 2022, and she, the two cook supervisors, and one food service supervisor were managing things in the kitchen as best they could. She added that all of the supervisors had years of experience, but none had the qualifications of a Certified Dietary Manager or Dietary Services Supervisor. 2. Multiple observations and interviews in the kitchen beginning 5/1/23 at 9:00 a.m. showed staff had inadequate position-specific staff training and competencies in place. 2A. Hair Restraints (Cross Reference F812) During observations in the kitchen beginning on 5/2/23 multiple staff did not have hair restrained: At 10:35 a.m. [NAME] A's hair hung down below the hair net in back. At 2:31 p.m. Food Service Technician 1 - H (FST H) had a hair net around her bun, but the rest of her hair was not contained. In a concurrent observation [NAME] B had hair straggling out from the sides of her hair net as she prepared apple pie (Cross Reference F812). Review of a policy titled Food & Nutrition Services - Staff operations and Training (All Homes) 6324 v.5 dated 4/11/23 showed employees shall wear hair restraints that covers body hair and is worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens. During an interview with the FSD on 5/3/23 at 11:52 a.m. she was asked about her expectations regarding hair restraints in the kitchen. She stated hair should be restrained, was aware of the hair restraint issues, and agreed several staff often did not have their hair fully covered because of the type of hair nets they chose. 2B. Handwashing and Glove Use (Cross Reference F812) During multiple observations in the kitchen between 5/1/23 at 9:00 a.m. and 5/3/23 at 5:00 p.m. staff wore gloves and touched multiple potentially contaminated surfaces such as doors, refrigerator doors, carts, and equipment from the floor without changing their gloves or without washing their hands between doffing (removing) soiled gloves and donning (putting on) new gloves (Cross Reference F812). During an interview with [NAME] Supervisor 2 (Cook S2) on 5/3/23 at 9:32 a.m., and with the FDS on 5/3/23 at 11:52 a.m. their responses regarding when staff should and should not wear gloves in the kitchen did not match (Cross Reference F812.). During an interview with the Administrator (ADMIN) on 5/4/23 at 11:00 a.m. she provided the facility's general infection control hand hygiene policy that included glove use and stated the facility did not have a glove use policy specific to Food and Nutrition Services. Review of the facility policy titled Hand Hygiene Procedure (All Homes), 7584 v.1, dated 12/24/22 showed Per the Centers for Disease Control (CDC) keeping hands clean through improved hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others. The section titled When Should I Use Soap and Water? included washing hands before and after your shift, before/during/after food preparation, before and during food service, before and after removing gloves. 2C. Equipment was not sanitary (Cross Reference F812). Review of a policy titled Food and Nutrition Services - Sanitation (All Homes), 6233 v.2, reviewed 10/7/2022, showed All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair. During observations in the kitchen between 5/1/23 at 9:00 a.m. and 5/3/23 at 5:00 p.m. the can opener had a buildup of food debris and there was black grime around the edge of the can opener mount. Two out of two observed ovens had black grime in the bottom and brown grease baked on the doors. During an observation and concurrent interview on 5/1/23 at 10:07 a.m., [NAME] S1 agreed two out of three observed floor drains in the cook's area were not clean. Review of documents titled RCFE, with various position titles, dated 4/3/23 through 5/3/23 showed the Cooks were responsible to clean the floors in the cook's area. The Weekly AM Clean Side/Caddies position was assigned to clean all can openers thoroughly, take out blue inserts and sanitize around the edge (of the can opener mount) on the table. All positions had assignments to clean some kind of fixed equipment. All of the assigned tasks reviewed were signed off by staff as completed. Specific assignments to clean the ovens or clean the floor drains was not found. 2D. Staff did not follow professional standards of practice or manufacturer's instructions to clean fixed equipment (equipment that cannot go through the dishwasher or be cleaned in a sink) (Cross Reference F812). During staff interviews on 5/3/23 between 2:00 and 3:00 pm, two (FST D, [NAME] B) out of three (FST E) staff stated they cleaned fixed equipment using only quat (quaternary ammonia) sanitizer solution. [NAME] B stated they never used soapy water to clean equipment, adding They told us to always use the quat water. FST E stated newer staff were being trained to only use quat sanitizer to clean equipment. During an interview with the FSD on 5/3/23 at 11:52 a.m. she stated fixed equipment was on a regular cleaning schedule that supervisors assigned. She stated staff used Quat sanitizer to clean equipment, and used some other cleaning chemicals occasionally. Review of the 2022 FDA Food Code 4-603.15, 4-603.16, 4-701.10 and 4-702.11 showed: equipment that cannot be cleaned in a sink or dishwasher shall be washed using detergents, have a distinct, separate rinse after washing so that abrasives and cleaning chemicals are removed, and then shall be sanitized before use after cleaning. Review of manufacturer's instructions for the department's quat sanitizer product directed for equipment to be washed with a good detergent and rinsed thoroughly with water before being sanitized with the sanitizer solution. They also required an at least 30 second wet time on food contact surfaces, and three minutes wet time on non-food contact surfaces. 2E. Kitchen ice machine was not sanitary (Cross Reference F812) During an observation and concurrent interview with FST 2B on 5/3/23 at 7:45 a.m., he stated he was assigned by supervisors to clean the ice machine. The kitchen ice machine was not clean. The department's instructions to clean it, and FST 2B's process to clean it did not match the manufacturer's instructions. During an interview with the Administrator (ADMIN) on 5/4/23 at 9:20 a.m. she stated she did not have any position specific training and competency checklists for most FANS staff, including FST 2B. There was no evidence FST 2B had been trained or was competent to clean the ice machine. 2F. Pureed foods did not meet texture/consistency standards. (Cross Reference F805). During an observation of lunch test trays, and concurrent interview with the FSD on 5/4/23 at 11:45 a.m., pureed foods did not meet consistency standards. The FSD agreed the pureed ham was grainy (not smooth). The pureed spinach, beans, and cornbread were thin and spread across the plate. The FSD described the strawberries with cream as almost watery thin .way too thin. Review of the facility specific diet manual, approved by the Registered Dietitians on 3/13/23 showed a description of the Regular Pureed Diet was The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. During an interview with the Food Service Director (FSD) on 5/1/23 at 11:32 a.m. she stated that after facility general orientation new staff were trained into their positions by supervisors and other staff, first observing, then helping, then working on their own. She stated they had done their first staff in-service since the pandemic the previous month and it was on therapeutic diets. She stated her goal was to get staff competencies in place as they attained full staffing. On 5/4/23 at 8:20 a.m., training and competency documents were requested for the following staff: Food Service Technician 1-C (FST C), FST E, Food Service Technician II-A (FST 2A), FST 2B, Food Services Supervisor A (FSS A), [NAME] A, [NAME] Supervisor 1 (Cook S1), and [NAME] S2. A review of the staff training and competency documents provided on 5/4/23 at 9:15 a.m. showed Food and Nutrition Services staff FST C, FST E, FST 2A, FST 2B, FSS A, [NAME] A, [NAME] S1, and [NAME] S2 completed the facility's initial, general, New Employee Orientation Checklist used for every staff hired in facility. It included Dietary Services which on 5/3/23 at 11:52 a.m. the FSD described was education about emergency food. An additional computer-generated list titled Course Completion History for each staff showed courses were completed on topics such as neglect, abuse, personal protective equipment, fire safety, first aid and ergonomics. Further review showed this training regarding staff: FST C - Three of 181 training events dated 3/2015 to current included position specific topics: Food Safety Fundamentals 5/7/2019, and Meals for All (disaster food/plan) 12/10/21 and 7/19/22. FST E - Five of 205 training events dated 1/2015 to current included FANS position specific topics: Basic Nutrition and Food Safety 8/11/22, Food Safety Fundamentals 7/27/19, Hand Hygiene the Basics 8/15/20, Meals for All (disaster food/plan) 7/28/21, 12/23/22. FST 2A - Six of 182 training events dated 7/2016 to current included FANS position specific topics: Basic Nutrition and Food Safety 1/23/22, Diets: Not Just for Weight Loss 5/1/21, Food Safety Fundamentals 6/1/19, 5/22/22, Meals for All (disaster food/plan) 6/30/21, 2/4/22. FST 2B - Three of 155 training events dated 1/2015 to current included FANS position specific topics: About Specialized Diets and Nutrition 5/18/16, About Renal Disease 5/19/16, Food Safety Fundamentals 5/28/19. FSS A - Five of 143 training events dated 7/2016 to current included FANS position specific topics: Basic Nutrition and Food Safety 7/10/22, Food Safety Fundamentals 5/28/19, 7/18/22, Meals for All (disaster food/plan) 10/10/21,7/26/22. Cook A - Two of 91 training events dated 6/2020 to current included FANS position specific topics: Food safety fundamentals 7/28/22, Meals for All (disaster food/plan) 7/28/22. Cook S1 - Six of 220 training events dated 3/2015 to current included FANS position specific topics: Basic Nutrition and Food Safety 1/22/22, Food Safety Fundamentals 5/7/19 and 5/15/22, Hand Hygiene the Basics 7/8/2015, Meals for All (disaster food/plan) 9/6/21, 2/7/22, and 3/15/23, Cook S2 - Two of 290 training events dated 5/2016 to current included FANS position specific topics: Meals for All (disaster food/plan) 6/26/21, 7/10/22. During an interview with the Administrator (ADMIN) on 5/4/23 at 9:20 a.m. she stated that for food services they only had position specific training and competency checklists for Food Service Supervisor A (FSS A), and for [NAME] Specialist A (Cook A). Review of FSS A's packet contained six checklist/competency documents signed off by FSS A and a supervisor on 6/4/22, and included topics surrounding kitchen safety, infection control in the kitchen, food preparation, handwashing, glove use, and correct sanitation, labeling and dating foods, preparing mechanically altered foods correctly, skills to supervise staff, and more. Review of [NAME] A's packet showed one document titled Supervising [NAME] 1 Competency, dated 11/2/22 and signed by [NAME] A and a supervisor. The document listed skills such as planning, organizing and preparing meals in appropriate quantity and quality, understanding therapeutic diets and modified texture diets, ability to supervise cleaning and care of equipment, kitchen sanitation, and more. They facility did not have position specific training and competency checklists in place for any of the remaining six Food and Nutrition Staff records requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation in the kitchen when: 1. Staff hair was not adequately restrained. 2. Staff did not consistently practice appropriate hand hygiene and glove use. 3. Equipment was not sanitary. 4. Equipment was not cleaned according to professional standards of practice. 5. The Dish Machine did not consistently provide accurate temperatures for staff to monitor and ensure its proper operation for cleaning and sanitizing dishes. 6. Ice machines in the kitchen and the nursing unit kitchenettes were not clean. 7. Nursing unit kitchenettes were not sanitary. These failures had the potential to result in foodborne illness for residents consuming food from the facility kitchen. Findings: 1. Staff Hair was not adequately restrained During observations in the kitchen on 5/2/23 multiple staff did not have hair restrained: At 10:35 a.m. [NAME] A's hair hung down below the hair net in back. At 2:31 p.m. Food Service Technician 1 - H (FST H) had a hair net around her bun, but the rest of her hair was not contained. In a concurrent observation [NAME] B had hair straggling out from her hair net as she prepared apple pie. During an interview with the FSD on 5/3/23 at 11:52 a.m. she was asked about her expectations regarding hair restraints in the kitchen. She replied staff wanted those little brown hair nets and they don't stay on. She was aware and agreed several staff often did not have their hair fully covered. 2. Staff did not consistently practice appropriate hand hygiene and glove use (Cross Reference F802) During an interview with the Administrator (ADMIN) on 5/4/23 at 11:00 a.m. she stated the facility did not have a glove use policy specific to Food and Nutrition Services and she provided the facility's general infection control hand hygiene policy that included glove use. Review of a policy titled Hand Hygiene Procedure (All Homes), 7584 v.1, dated 12/24/22 showed Per the Centers for Disease Control (CDC) keeping hands clean through improved hand hygiene is one of the most important steps we can take to avoid getting sick and spreading germs to others. The section titled When Should I Use Soap and Water? included washing hands before and after your shift, before/during/after food preparation, before and during food service, before and after removing gloves. Review of the 2022 FDA Food Code §3-301.14 showed Food employees shall clean their hands and exposed portions of their arms .after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning (putting on) gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. FDA Food Code 3-304.15(A) showed Single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. During an observation in the dish room on 5/1/23 at 9:05 a.m. FST A removed food debris from resident's soiled breakfast dishes using her bare hands. She stated she was working the clean side of the dish room that day but was just helping the dirty side with silverware for a minute. During multiple observations in the dish room on 5/1/23 at 9:41 a.m., FST A, Food Service Technician 2-A (FST 2A), and FST C worked the clean side of the dish machine and did not wear gloves when removing clean dishes from the dish machine racks. FST 2B wore gloves as he put away clean plates, then removed his gloves and washed his hands. FST A donned gloves and pushed a cart containing clean plates, plate guards and some other equipment through the kitchen. A plate guard fell off the cart and onto the floor. FST A picked up the plate guard from the floor with her gloved hands and placed it in the dirty section of the dish room. She did not change her gloves or wash her hands before continuing to push the cart of dishes through a door. She came back with the cart empty. She did not change her gloves or wash her hands. During an observation on 5/1/23 at 11:03 a.m. FST A wore the same gloves as she put resident meal tray tickets and preference cards on tray line, touched the kitchen doors as she pushed the resident meal cart to the nursing unit, and returned to work in the kitchen without removing or changing her gloves. In a concurrent observation FST C wore the same gloves as she pushed the door coming in from the dining room, put resident meal tray tickets on tray line, and touched the doors again as she traveled again between the kitchen and dining room. During an observation on 5/2/23 at 10:15 a.m. [NAME] A wore gloves from the Cook's food preparation area, touched both the walk-in refrigerator and the dry storage room doors while entering and exiting, then returned to work in the Cook's food preparation area without washing hands or changing gloves. In a concurrent observation, [NAME] Supervisor 1 (Cook S1) wore gloves and touched the walk-in refrigerator door handles when entering and exiting, then went back to food preparation wearing the same gloves. During an observation on 5/2/23 at 10:35 a.m. [NAME] A changed gloves without washing hands during food preparation. During an observation on 5/3/23 at 7:45 a.m. [NAME] A wore gloves while making salads. She entered and exited the walk-in refrigerator, touching the door with her gloves, then went back to making salads with no glove change or handwashing. During an interview with [NAME] S2 on 5/3/23 at 9:32 a.m. he stated staff should wear gloves at all times in the kitchen, during food production, and when handling food or items for residents. He stated gloves should be worn any time cross contamination would be a concern. [NAME] S2 explained staff would not need to wear gloves when signing in for work or filling out daily logs. He stated wearing gloves was optional for staff working on the dirty side of dish room since the gloves were for their own protection and did not endanger residents. [NAME] S2 stated once an item (food or equipment) was touched it was potentially soiled/contaminated. He stated when staff put away clean dishes their hands should be clean, and they did not need to wear gloves. In addition, if a cart had been sanitized, there was no concern for cross contamination and staff didn't need to wear gloves. [NAME] S2 stated if staff touched a door, they would need to wash their hands and put on new gloves. During an interview with the Food Service Director (FSD) on 5/3/23 at 11:52 a.m. she stated that to avoid cross contamination she would expect her staff to wear hairnets, wash their hands, wear gloves, and ensure surfaces were sanitized timely. She stated if staff went to another area, or if they touched the walk-in refrigerator handle or door, yes, they should change their gloves. She stated staff who worked on either the dirty side or the clean side of the dish room should wear gloves. Everyone in the kitchen should be wearing clean gloves at all times. Any position actively engaged (in the kitchen) should wear clean gloves. The FSD further stated staff should wash their hands when entering the kitchen and before putting on gloves, and staff should change their gloves and wash their hands whenever they touched something that could cross contaminate their gloves. The FSD stated if staff handled trash, picked something up off the floor, or delivered a cart they should change their gloves and wash their hands. 3. Equipment was not Sanitary (Cross Reference F802) Review of a policy titled Food and Nutrition Services - Sanitation (All Homes), 6233 v.2, reviewed 10/7/2022, showed All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair. During an observation in the kitchen on 5/1/23 at 10:07 a.m. the floor drains near the cook's prep sink and the floor drain near the cook's prep area were soiled with brown grime. The basin of the floor drain near the cook's fire extinguisher was clean but the floor around it had an accumulation of black and brown grime. In a concurrent interview, [NAME] S1 confirmed two out of three floor drains were not clean. During an observation in the kitchen on 5/1/23 at 10:10 a.m. the can opener blade had food debris, and its mount had an accumulation of black grime around the edges. During an observation on 5/2/23 at 10:15 a.m. two of two ovens observed had a buildup of black grime in the bottom, and brown grease baked on to the doors. 4. Equipment was not cleaned according to professional standards of practice or per manufacturer's instructions (Cross Reference F802). Review of the 2022 FDA Food Code 4-603.15, 4-603.16, 4-701.10 and 4-702.11 showed: equipment that cannot be cleaned in a sink or dishwasher shall be washed using detergents, have a distinct, separate rinse after washing so that abrasives and cleaning chemicals are removed, and then shall be sanitized before use after cleaning. During an interview with FST D on 5/2/23 at 2:31 p.m. she stated part of her job was to clean up tray line after dinner. She stated the process for cleaning equipment such as the tray line was to wash the counter down with Quat (Quaternary Ammonia) Sanitizer, then use a clean towel to dry it off so it was shiny. When asked if they ever washed the equipment down with soapy water, FST D replied no, but sometimes they cleaned it with white vinegar first and did a double clean that way. During an observation and concurrent interview with [NAME] B on 5/2/23 at 2:31 p.m., she prepared apple pie for the dinner meal. She stated at end of her evening shift she cleaned her stationary equipment using a Quat sanitizer rag. When asked if they ever used soapy water to clean it she stated no, they told us to always use the quat water. During an interview with FST E on 5/2/23 at 2:48 p.m. she stated I like to use hot soapy water to wash things down. Then rinse, then sanitize. She added that newer staff were being trained to only use sanitizer to clean equipment. I was trained different (due to her longevity at the facility). Review of the manufacturer's instructions for Sani-Guard 24-7 Food Contact Surface Sanitizer used by the facility kitchen showed: TO SANITIZE FOOD CONTACT SURFACES: For sanitizing hard non-porous surfaces of food processing equipment .food utensils, dishes, silverware, glasses, sink tops, countertops, refrigerated storage and display equipment and other hard nonporous surfaces. Prior to application, remove gross food particles and soil .Then thoroughly wash or flush objects with a good detergent or compatible cleaner, followed by a potable water rinse before application of the sanitizing solution .Use a solution of .150-400 ppm active quat or equivalent dilution to precleaned hard surfaces thoroughly wetting surfaces .Surfaces must remain wet for at least 60 seconds followed by adequate draining and air drying. Do not rinse. TO SANITIZE NON-FOOD CONTACT SURFACES: Add ¼ oz. of Sanit-Guard 24-7 per gallon of water .To sanitize precleaned hard, non-porous surfaces .apply sanitizer use-solution .thoroughly wetting surfaces .treated surfaces must remain wet for 3 minutes. Wipe dry with a sponge, mop or cloth or allow to air dry. Staff did not wash and rinse stationary equipment prior to sanitizing it, and they did not ensure the required wet time occurred for the sanitizer to work properly (Cross Reference F802). 5. The Dish Machine did not consistently provide accurate temperatures for staff to monitor and ensure its proper operation for cleaning and sanitizing dishes (Cross Reference F908). Review of a policy titled Food & Nutrition Services - Warewashing Manual & Mechanical (All Homes), 6703 v.3, review date 10/7/2022, showed A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of contaminated equipment .Dishwashing machines, operated according to the manufacturer specifications, washed, rinsed, and sanitize dishes and utensils using either heat or chemical sanitation. Dish Machines .wash temperature will be between 150-165°F (degrees Fahrenheit); and hot water at a minimum temperature of 180°F will be maintained at the manifold of the final rinse. During an observation in the dish room on 5/1/23 at 9:55 a.m., FST C worked on the dirty side of the dish machine. In a concurrent interview she stated there was a problem with the dish machine and it had been ongoing for years. She explained the final rinse temperature would hit 180°F (degrees Fahrenheit), and then dropped rapidly. During further observation of the function of the dish machine, the temperature screen showed the final rinse temperature dropped from 180°F to 168°F as racks continued to move through the machine. FST C stated the dish machine temperatures should be 160°F or greater for the wash and rinse, and 180°F or greater for final rinse. FST C also stated there was a problem with the rinse agent (a chemical that helps water to sheet off dishes, so they dry quickly and have fewer water spots) and it had not been working at all for a week. She stated it had happened before, but the repair vendor was different from the dish machine repair vendor. Review of the Manufacturer's specification plate on the dish machine showed for hot water sanitizing the temperature requirements were wash 160 minimum, and final rinse 180°F minimum to 194°F maximum. During an interview with Food Service Supervisor A (FSS A) on 5/1/23 at 10:15 a.m., she stated the Assistant Administrator (ASADMIN) went to their warehouse to see if there were any temperature test strips that could be run through the dishwasher. She explained that in the past they had run temperature strips through the dish machine when there were issues with the dish machine temperature readings, and they had especially had problems with this and used the strips in January. FSS A added she hadn't noticed any big issue with that again until recently. She stated she thought it was an electronics issue rather than a temperature issue, but there had been a lot of issues with the dish machine. FSS A explained that after the repair vendor came, the electronic temperature reader worked well for a while but then went out again. She stated the rinse agent dispenser problem was from a fuse going out, and the service vendor had come several times to fix it. During an interview with FST F on 5/2/23 at 2:13 p.m. she was asked how she knew if the dish machine was working properly. She stated she knew by the noises it made. Also, the final rinse temperature should be 180°F, middle temp (first rinse) 160 or above, and wash temp should be 165°F or higher. If the temps weren't registering correctly, she would get a supervisor. During an interview with [NAME] S2 on 5/3/23 at 8:10 a.m. he stated that in the past, the dish machine temperatures had dropped from 180°F to 170°F. If the temperature was out of range, staff got a supervisor and they used a temperature test strip to check it. When they were having problems with the temperatures, the supervisor did a test strip daily for QAPI. [NAME] S2 stated the machine was repaired in December or January, and the service vendor repaired the mother board, the lines, and gave it a complete overhaul. He stated the rinse agent vendor came to fix the rinse agent the previous Thursday, yet according to staff it still wasn't working. During an interview with the FSD on 5/3/23 at 11:52 a.m. she was asked about the dish machine temperature issues and what had been done to resolve them. She stated the current dish machine was four years old, and they had ongoing problems with it. One problem they identified was the repair vendor had used inferior, substandard parts to repair it. Review of a policy titled Food & Nutrition Services - Equipment (All Homes), 6227 v.2, review date 4/12/2023, showed Equipment will be provided and maintained in good working order. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operation. Review of documents titled Dish Machine Temperature & Chemical Record, Main Kitchen, dated 11/1/22 through 4/30/23 showed the wash and final rinse temperatures were checked by staff five times each day. Temperatures were documented within the correct range on all checks and dates except for 15 checks on dates 12/6/22 (x3), 12/10/22 (x1), 12/11/22 (x2), 12/13/22 (x1), 12/16/22 (x3), 12/24/22 (x1), 12/26/22 (x4). Review of additional documents titled HACCP Temperature Checks showed temperature strips were run through the machine five out of 15 times when temperatures were documented out of range (12/6/22 x2, 12/13/22 (x1), 12/16 x1, and 12/24 x1). The HACCP Temperature Checks also showed additional temperature strip checks 12/3, 12/15, 12/27 (x2), and 1/23/23. The HACCP Temperature Checks did not reflect temperature strips were run through the dish machine daily during the timeline of out-of-range temperatures to ensure food safety, and there were no temperature strips readily available for supervisors to check the dish machine final rinse temperatures when they were questioned on 5/1/23 at 9:55 a.m. 6. Ice Machines in the kitchen and nursing unit kitchenettes were not sanitary. Review of a policy titled Food and Nutrition Services - Sanitation (All Homes), 6233 v.2, reviewed 10/7/2022, showed Ice used in connection with food or drink will be from a sanitary source, and will be handled and dispensed in a sanitary manner. Ice machines will be cleaned according to manufacturer's guidelines. Review of a policy titled Ice Machine Maintenance and Cleaning 6055 .1, dated 10/18/22 showed The Home's staff will adhere to manufacturer's instructions recommended maintenance, cleaning and sanitizing procedures to ensure trouble free operation of the ice machines. Food Nutrition Services will clean the outside of the Ice-O-Matic ice machines. They will remove the ice from the machine's reservoir and the reservoir will be sanitized on a schedule as recommended by the manufacturer's instructions. Plant Operations will inspect the ice machine every three months. The general maintenance and filter change will be performed every six months. In addition Plant Operations will clean and sanitize the internal parts at least every six months as needed. During an interview with the Plant Operations Director (POD) on 5/3/23 at 8:20 a.m. he stated cleaning ice machines in the facility was a joint effort between Plant Ops, Housekeeping and Nursing. He thought the kitchen ice machine was cleaned daily by the kitchen, and Plant Ops changed the filters and did the descaling PM (preventive maintenance) every 30 to 90 days. When asked how staff in the other departments knew how to clean the ice machines correctly, he stated he didn't know because his department was only responsible for the filters and descaling. He stated responsibility for hard water deposits would fall under daily cleaning (by the other departments). 6A. The kitchen ice machine was not sanitary. Review of the Ice-O-Matic Ice Machine Cleaning and Sanitizing Instructions provided by Plant Operations and dated 11/08 showed Maintenance and Cleaning should be scheduled at a minimum of twice per year. It directed use of approved nickel safe ice machine cleaner to the water trough according to label instructions in the wash cycle .remove the splash curtain and inspecting the evaporator and water spillway to ensure all mineral residue was removed .remove and clean the water distribution tube .clean the water trough thoroughly to remove all scale or slime build-up .if necessary remove the water trough to reach all splash areas and float .use sodium hypochloride food equipment sanitizer with 100-200 ppm .to fill the water trough .switch to wash position and circulate for 10 minutes. Inspect all disassembled fittings for leaks .wipe down all other ice machine splash areas plus the interior surfaces of the bin, deflector and door with the remaining sanitizer solution .flush the sanitizer down the drain, turn machine on to further purge the sanitizing solution .discard the first two ice harvests. Review of undated Food and Nutrition Services instructions posted on the ice machine, titled Procedure for monthly Ice Machine Cleaning and Sanitizing directed staff to remove the ice .properly sanitize the inside of the ice machine using a food grade quaternary sanitizer .liberally spray the inside of the cabinet with the sanitizer and clean with a brush .Let the sanitizer sit for a few minutes before rinsing thoroughly with clean warm water. Do not touch or wipe out the inside of the cabinet. Air dry. Turn machine back on. The most important thing is to thoroughly sanitize the machine and return the unit to working status. If any questions arise during this process check with your immediate supervisor. The term cabinet was not defined, or its function described in the instructions. The instructions did not match the manufacturer's. During an observation of the kitchen's Ice-O-Matic ice machine and concurrent interview with FST 2B on 5/3/23 at 7:45 a.m. he stated he cleaned the ice machine when supervisors assigned him to do it, and he was the only kitchen staff ever assigned to do it in a long time. Plant ops would be the other ones who do it (clean the ice machine). Further concurrent interview with FST 2B and observation inside the ice machine showed white mineral deposits over multiple surfaces, and a brownish-black substance on a white tube, and also along the bottom of the cuber. A white paper towel wiped across the white tube, and a second white paper towel wiped across the bottom of the cuber returned a black substance resembling mold. FST 2B stated he last cleaned the ice machine 3/15/23. Review of a Food and Nutrition Services document titled Ice Machine Sanitizing Log 2023 showed it had been cleaned once in 2023 on 3/15/23. The log stated Empty and sanitize with multi-quat sanitizer, let cabinet air dry and included supervisor's initials on 3/15/23. FST 2B described this process he used to clean the ice machine: Turn the machine off. Empty the ice bin, remove the cuber cover, push the purge sump button. He noted the white tube inside the machine leaked a lot of water but was not supposed to leak water. Spray and rinse everything down and sanitize it with Sani-Guard 24-7 Quat sanitizer. Rinse it down with water, push the sump pump purge button again, and hand wash the cuber cover. Push the wash button. Wash the whole outside of the machine by hand with sanitizer. Clean the ice fall catcher and lids with sanitizer. When the upper part is done clean the seals and corners, squeegee water down the drain in the ice bin, and wipe out with sanitizer rag. Air dry. Turn on to run, discard two batches of ice before use. FST 2B stated no other chemicals were used in the machine, but he occasionally used a green scrubby tool on the mineral deposits. He stated the machine should not have any mold because it had an antimicrobial liner. During an interview with [NAME] S2 on 5/3/23 at 8:10 a.m. he stated the ice machine was cleaned inside at the end of each month by FST 2B, the procedures were posted on the machine, and Plant Ops cleaned it quarterly. He stated staff could go to any supervisor on shift to guide them in cleaning the machine, and they just used quat sanitizer to clean it. They did not use bleach or any other chemicals. During an observation of the kitchen Ice-O-Matic Ice Machine and concurrent interview with the plumber ([NAME]) and the ASADMIN on 5/3/23 at 9:09 a.m., [NAME] described this process to clean the kitchen ice machine: Remove Cover. Turn Off. Dump and remove Ice. Add Nickel Safe Ice Machine Cleaner solution to tray. Press button to activate the Cleaning Cycle. It takes about 15 minutes. Use a brush to clean inside the white hose. Repeat with IMS-III Sanitizer. Wipe the whole thing down with Nickel Safe Machine Cleaner. That's basically it. He stated he last cleaned the kitchen ice machine a couple of weeks ago. The ASADMIN took the ice machine out of service until it could be cleaned. This process did not include ensuring all mineral deposits were removed or cleaning the water trough as described in the manufacturer's instructions. Review of Plant Operations documents posted near the ice machine titled Ice-O-Matic Cleaning & Sanitizing (3 month intervals) Location: Main Kitchen, Year/ 2023, showed instructions to clean the ice machine using nickel safe ice machine cleaner and approved sanitizing solution, and each step was signed off as completed 1/12/23 and 4/15/23. Despite these efforts the ice machine was not clean. During an interview with the Administrator (ADMIN) on 5/4/23 at 9:20 a.m. she stated she did not have any position specific training and competency checklists for most FANS staff, including FST 2B. There was no evidence FST 2B had been trained or was competent to clean the ice machine. 6B. The nursing kitchenette ice machines were not sanitary. During observations of the two skilled nursing unit resident food kitchenettes on 5/1/23 between 3:00 p.m. and 4:00 p.m., each unit contained a [NAME] ice machine with white mineral deposits on ice chutes and other exterior surfaces. In a concurrent interview with the Quality Assurance Nurse (QAN), he stated the CNAs (Certified Nursing Assistants) on NOC (night) shift cleaned the exterior of the ice machines, and Plant Ops cleaned the inside. Documents posted on the ice machines titled [NAME] ICE Machine Cleaning Directions indicated nursing's night shift was to clean the outside of the ice machine with soap and water each night. Environmental Services (EVS) was to disinfect the outside of the ice machine daily including the drain pan and drain line. Plant Operations was to do maintenance every three to six months, including cleaning the inside of the machine. Further instructions directed nursing to remove the covers from the ice tubes (chutes), wash them with soapy water, and rinse them nightly. Then wash and rinse the ice chutes nightly. EVS was directed to use Cell Block 64 (food safe) disinfectant to clean and then rinse the covers daily. The documents further showed The inside of the ice tubes build up white material, which harbors bacteria. Please be sure to clean and/or disinfect the inside of the ice tubes. Replace the covers over the ice tubes after cleaning/disinfecting. Nursing clean the ice tray with soap and water and then rinse. EVS disinfect the drain pan with cell block 64, allow 10-minute dwell time, rinse. Pour 1 gallon of hot tap water into the drain pan and drain line. We must be proactive in cleaning and disinfecting the ice machines of the Home. Ice machines are known for cross contamination so cleaning and maintenance of the ice machine are important. Review of documents titled CNA Monthly NOC Shift Unit Duties & Cleaning Log dated April, 2023 showed CNA's were assigned to clean the kitchenettes, check food dates, discard expired products, clean the ice machine, check the dishwasher temperatures, and were signed off daily by the CNA's. During an observation and concurrent interview in the nursing unit kitchenette on 5/3/23 at 8:25 a.m. Maintenance Engineer A (ME A) stated EVS disinfected the outside of the ice machine daily, including cleaning the drain pan and drain line, and Plant Ops did the interior maintenance every three to six months. During an interview with the Custodian Supervisor (CUST) on 5/3/23 at 8:45 a.m. he stated EVS staff cleaned the area around the exterior of the ice machine using sanitizer and chrome polish on the outside. They used Cell Block Sanitizer. The CNA's do the chute area with Vanguard 24-7 Food Safe chemical, and Plant Ops cleans the inside. In an additional observation with concurrent interview in the nursing unit kitchenette on 5/3/23 at 8:54 a.m., the plumber ([NAME]) stated he deep cleaned every ice machine in the facility including the kitchenette [NAME] ice machines and the kitchen Ice-O-Matic ice machine. The Follet ice machines were wiped down daily by nursing staff, and he deep cleaned them. He stated he was only responsible for two hoses. He didn't clean them, but instead replaced them with new ones every three months. He described this process for cleaning the [NAME] Ice Machines: He poured water into the cleaning cup, ran it through the machine for 15 minutes, dumped it, then repeated the process with sanitizer. He removed, cleaned, and descaled the chutes, ice tray and drain pan every three months. He stated the cleaner-descaler product didn't remove mineral deposits. He replaced the water filters every 6 months. Review of the undated manufacturer's instructions for cleaning/descaling and sanitizing the Follet ice machines #208595, provided by Plant Ops showed the recommended cleaning procedures should be performed at least as frequently as recommended and more often if environmental conditions dictate, and should be performed by trained maintenance staff or a Follet authorized service agent. Cleaning/descaling and sanitizing of the ice machine and dispenser should be done Semi-Annually (more often if conditions dictate). The PLUMBs process was similar to the manufacturer's process except he replaced two hoses quarterly, and he did not describe soaking the ice compression nozzle and drain lines first in cleaner/descaler solution for up to 45 minutes, and then in sanitizer for approximately 30 minutes. The kitchenette ice machines had an accumulation of white mineral deposits. 7. Nursing Unit kitchenettes were not sanitary. During an observation of the resident food kitchenette on the [NAME] memory care unit on 5/1/23 at 3:00 p.m., the room contained a refrigerator, stove, sink and lots of cabinets. Certified Nursing Assistant A (CNA A) was emptying resident water pitchers into kitchen sink and discarding them. The interior of the resident refrigerator was soiled with spilled food. There was a soiled mug in the sink. The ice machine was unclean with a buildup of white mineral deposits, and a drawer showed dried brown liquid. The refrigerator and freezer were full of food and beverages from the facility and from outside the facility. Only food provided by the facility was labeled and dated. The counter was piled with additional boxes of sodas, cereal bars, popcorn and other resident food. A cabinet held an unlabeled, undated bag of candy. In a concurrent interview with the Quality Assurance Nurse (QAN) he stated the expectation for the kitchenette was that the kitchen stocked the refrigerator, and food from the outside was supposed to be labeled with the resident's name. Review of documents titled CNA Monthly NOC Shift Unit Duties & Cleaning Log dated April, 2023 showed the CNA's were assigned daily to Clean Ice Machine .Kitchenette - Clean the fridge and freezer inside and out. Clean the stove, microwave, dishwasher, dishes in the sink and counter tops etc .Remove outdated items from the freezer and fridge .Nursing is responsible for removing items with expiration dates that the Resident's brings in. Discard any expired items found .Temp check the dishwashers. All of the tasks were signed off by staff on the [NAME] and Klamath Units 29/30 days. During an interview with the ADMIN on 5/4/23 at 11:00 a[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the dish machine consistently provided accurate temperatures so staff could monitor its proper function for cleaning and sanitizing dishes. This failure had the potential to result in foodborne illness for residents consuming food in the facility (Cross Reference F812). Findings: Review of a policy titled Food & Nutrition Services - Warewashing Manual & Mechanical (All Homes), 6703 v.3, review date 10/7/2022, showed A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of contaminated equipment .Dishwashing machines, operated according to the manufacturer specifications, washed, rinsed, and sanitize dishes and utensils using either heat or chemical sanitation. Dish Machines .wash temperature will be between 150-165°F (degrees Fahrenheit); and hot water at a minimum temperature of 180°F will be maintained at the manifold of the final rinse. Review of a policy titled Food & Nutrition Services - Equipment (All Homes), 6227 v.2, review date 4/12/2023, showed Equipment will be provided and maintained in good working order. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operation. During an observation in the dish room on 5/1/23 at 9:55 a.m., FST C worked on the dirty side of the dish machine. In a concurrent interview she stated there was a problem with the dish machine and it had been ongoing for years. She explained the final rinse temperature would hit 180°F (degrees Fahrenheit), and then dropped rapidly. During further observation of the function of the dish machine, the temperature screen showed the final rinse temperature dropped from 180°F to 168°F as racks continued to move through the machine. FST C stated the dish machine temperatures should be 160°F or greater for the wash and rinse, and 180°F or greater for final rinse. Review of the Manufacturer's specification plate on the dish machine showed for hot water sanitizing the temperature requirements were wash 160 minimum, and final rinse 180°F minimum to 194°F maximum. During an interview with Food Service Supervisor A (FSS A) on 5/1/23 at 10:15 a.m., she explained that in the past they ran temperature strips through the dish machine when there were issues with the dish machine temperature readings, and they had especially had problems with this and used the strips in January. FSS A added she hadn't noticed any big issue with that again until recently. She stated she thought it was an electronics issue rather than a temperature issue, but there had been a lot of issues with the dish machine. During an interview with FST F on 5/2/23 at 2:13 p.m. she was asked how she knew if the dish machine was working properly. She stated she knew by the noises it made. Also, the final rinse temperature should be 180°F, middle temp (first rinse) 160 or above, and wash temp should be 165°F or higher. If the temps weren't registering correctly, she would get a supervisor. During an interview with [NAME] S2 on 5/3/23 at 8:10 a.m. he stated that in the past, the dish machine temperatures had dropped from 180°F to 170°F. If the temperature was out of range, staff got a supervisor, and they used a temperature test strip to check it. When they were having problems with the temperatures, the supervisor did a test strip daily for QAPI. [NAME] S2 stated the machine was repaired in December or January, and the service vendor repaired the mother board, the lines, and gave it a complete overhaul. During an interview with the FSD on 5/3/23 at 11:52 a.m. she was asked about the dish machine temperature issues and what had been done to resolve them. She stated the current dish machine was four years old, and they had ongoing problems with it. One problem they identified was the repair vendor had used inferior, substandard parts to repair it. Review of documents titled Dish Machine Temperature & Chemical Record, Main Kitchen, dated 11/1/22 through 4/30/23 showed the wash and final rinse temperatures were checked by staff five times each day. Temperatures were documented within the correct range on all checks and dates except for 15 checks on dates 12/6/22 (x3), 12/10/22 (x1), 12/11/22 (x2), 12/13/22 (x1), 12/16/22 (x3), 12/24/22 (x1), 12/26/22 (x4). Review of additional documents titled HACCP Temperature Checks showed temperature strips were run through the machine five out of 15 times when temperatures were documented out of range (12/6/22 x2, 12/13/22 (x1), 12/16 x1, and 12/24 x1). The HACCP Temperature Checks also showed additional temperature strip checks 12/3, 12/15, 12/27 (x2), and 1/23/23. The HACCP Temperature Checks did not reflect temperature strips were run through the dish machine daily during the timeline of out-of-range temperatures to ensure food safety, and when the final rinse temperatures dropped again on 5/1/23 at 9:55 a.m., there were no temperature strips readily available for supervisors to check the dish machine final rinse temperatures.