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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: 1. Metoprolol injectable vials (intravenous medication use to treat high blood pressure, and heart problems), were not stored and protected according to manufacturer recommendations for 1 of 1 pharmacy storage areas reviewed. 2. The nursing staff discarded MediSense (a brand name) glucose control solution (a solution with a specific known concentration of sugar used to calibrate and check the accuracy of a blood glucose meter) vials, when they expired. This failure had the potential to affect the stability and effectiveness of medications administered to residents and produced inaccurate patient blood glucose test results which could have led to negative clinical outcomes. Findings: 1. During an observation on [DATE] at 11:00 am, in the facility's pharmacy, three injectable vials of metoprolol were stored in a small container directly under an overhead light. The vials were not enclosed in an amber bag, or otherwise shielded from light. Review of the manufacturer's guidelines product insert for metoprolol under the heading titled, Supplied /Storage and Handling, dated [DATE], indicated metoprolol must be protected from heat and light to preserve its stability and potency. During an interview on [DATE] at 2:00 pm, with Director of Pharmacy (DOP), DOP confirmed the vials of metoprolol were not protected from light. DOP confirmed the vials should have been protected from light. Review of the facility's policy titled, Medication Management; Storage of Medications, dated 12/2024, indicated medications must be stored under proper conditions of sanitation, light, humidity, ventilation, segregation and security as determined by the manufacturer's labeling. 2. During a concurrent observation and interview, on [DATE] at 8:35 am, in the medication room, with Assistant Director of Nursing (ADON), two MediSense glucose control vials, one labeled HI and one labeled LOW, had the manufacturer's printed expiration date of [DATE]. ADON confirmed the expiration date on the vials were [DATE], and should have been checked and discarded by the nursing staff. Review of the manufacturer's guideline for MediSense Glucose and Ketone Control Solutions, dated 7/2019, under the heading of Storage and Handling, indicated, discard control solutions 3 months after opening or on the expiration date printed on the bottle, whichever comes first. Under the heading, Precautions and Warnings, indicated do not use control solutions if they are expired. Review of the facility's policy titled, Nursing; Fingerstick Blood Glucose, dated 12/2024, indicated the meter will be cleaned, maintained and properly calibrated per manufacturer's guidelines.

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to carry out a resident's wishes for end of life treatment when the facility staff performed cardiopulmonary resuscitation (CPR, an emergency life-saving procedure when breathing or heart beat has stopped ), on one of three sampled residents (Resident 1) that chose not to have CPR not be performed. This resulted in Resident 1 receiving CPR and violated her end of life wishes. Findings: A review of the facility's policy titled, CODE BLUE [means someone is experiencing a life threatening medical emergency where their heart stopped or they are not breathing and staff are to respond immediately] reviewed 5/2021, indicated, Section C: A 'CODE BLUE' will be called on all patients who experience a cardiac and/or respiratory arrest unless a DNR [Do not resuscitate means the same as No CPR] order is written on the patient's chart. Resident 1 was admitted to facility on [DATE] with a diagnosis of high blood pressure and congestive heart failure (CHF, when the heart is unable to pump enough blood to the body and fluid builds up in the lungs). A review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST, a document signed by a resident or their responsible party which specifies their end of life wishes), dated [DATE], indicated that Resident 1 desired No CPR. A review of Resident 1's Physician's Orders dated [DATE], indicated the physician had discussed CPR with Resident 1 and her family member and an order was written for DNR. A review of Resident 1's Progress Notes dated [DATE] at approximately 8:18 PM, indicated Resident 1 was found, unresponsive . without a detected pulse. A Code Blue (means someone is experiencing a life threatening medical emergency and the heart stops or they are not breathing and staff need to respond immediately) was called. Facility staff responded and began doing CPR on Resident 1. On [DATE] at 8:30 AM, an interview was conducted with the Chief Nursiing Officer (CNO). The CNO confirmed that Resident 1 had documented wishes for No CPR on her POLST and on her Physician's Orders, and should not have received CPR. The CNO added that there had been confusion with the verbiage on the POLST form and the facility has since revised the POLST form and implemented a new process. On [DATE] at 8:00 AM, Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, I was in getting meds for another patient and I heard the code called. I had to finish there and then I was able to go to the patient's [Resident 1] room. I was thinking that it is a DNR patient and I went in and confirmed that. I let everyone know [Resident 1] was a DNR patient. The doctor was there about the same time as me and was on the phone talking to [Resident 1's] family and the family member told us to continue CPR. The doctor told us to continue. I came in after it was started. I told everyone she was a DNR but CPR was already being performed. There was some confusion apparently about what type or level it was. On [DATE] at 8:40 AM the Medical Doctor (MD)1 was interviewed. MD 1 stated, I was in house [in the hospital] and responded to the code. I was told there was a POLST form and was told [Resident 1] was a DNR and I called [a family member]. That [family member] didn't answer so I called [another family member], who said since we were already coding [giving CPR] to continue and transport [Resident 1] to the hospital.

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

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

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

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

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two out of six sampled residents, (Resident 10 and Resident 21) was free from abuse and neglect when: a Certified Nursing Assistant (CNA) F was verbally rude, disrespectful, and did not provide care when requested. This failure caused Resident 10 and Resident 21 increased anxiety, loss of dignity, and humiliation. Findings: 1. During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. The facility recognizes and supports the laws, rules, and regulations that require all employees to report incidents of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property to the administrator of the facility, and to other officials in accordance to state law. This policy addresses the four key components of a comprehensive abuse prevention program. The four components are abuse prevention procedures, abuse reporting and investigation procedures, findings and response, and documentation. The facility's policy revised 01/2023, titled, Promoting/Maintaining Resident Dignity, directed facility staff to protect and promote resident rights, and treat each resident with respect and dignity as well as care for each resident in a manner that maintains or enhances resident's quality of life by recognizing each resident's individuality. This policy indicated the resident's personal choices will be considered when providing care and services, respond to requests for assistance in a timely manner, speak respectfully to residents, and each resident will be provided equal access to quality care regardless of a diagnosis, severity of condition, or payment source. 1. A review of Resident 10's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a spinal cord injury, Lupus, (a progressive disease that occurs when your body's immune system attacks your own tissues and organs) and suprapubic catheter, (a urinary catheter that drains urine directly from the bladder), and diabetes. A review of the most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/10/22 indicated that Resident 10 was cognitively intact (able to think and reason) and required extensive assistance and is totally dependent on staff for all activities of daily living. During an interview on 2/14/23 at 11:19 am, Resident 10 stated, I am having a problem with a CNA. CNA F is rude and always has an attitude. CNA F left me uncomfortable, and refused to move my incontinent pad under me, it was up to my neck. When I asked CNA F to reposition the incontinent pad under me, she walked off and stated, You are fine. Oh, well. My roommate heard her too. CNA F was in a hurry when she was changing my gown and pulled at my port-a-cath access, (surgical access to administer Intravenous medications). She needs more training; she needs to slow down. I reported all of this to Licensed Nurse (LN) A and told her CNA F needs more training. She was supposed to do an investigation and let me know the results. I never heard back from LN A about it, or anyone, but CNA F has been taken off my room schedule. I have not seen CNA F, but I would like an update. It has been a week or two since I reported it to LN A. I told LN A I was afraid of retaliation, and she told me she would keep it in confidence. They have put me in a depression, it has been so hard, I felt like I was in trouble. During an interview on 02/14/23 at 12:02 pm, Resident 21 stated, I worry about my roommate, they do not treat her right. It hurts me the difference in the way they treat me and Resident 10. They single her out for some reason, I remember Resident 10 reporting CNA F. I agree with everything she said, it is the truth. During an interview on 02/14/23 at 3:18 pm, LN A stated, I do remember Resident 10 complaining about a CNA F, last week or the week before. I am not sure if it was accidental or purposely done, the CNA F hit her legs twice, seemed like the CNA was frustrated is what she told me. The CNA hit her legs twice while moving her in the bed, her pad was up to her neck is what was reported, but not when I went in. I cannot remember who reported the complaint, but I did talk to CNA F after it was reported to me. Yes, Resident 10 told me she was afraid of retaliation, but I told her it would be in confidence. No, I did not make a note, I know I should have made a note, but I did remove CNA F off the schedule from her room. Yes, Resident 10 did say the pad was uncomfortable and not being in the right place, but I don't remember the comment the CNA F stated, Oh well. CNA F stated to me I did not mean to push her legs; I will make sure the pads are placed correctly. I did coach CNA F, teaching, and counseling. CNA F agreed to put the pads in a correct manner. I called the Assistant Director of Nursing (ADON), she had already gone home, she was not here in the facility. She had me to talk to CNA F, I wasn't sure if it was accidental or on purpose. Yes, I did talk to CNA F about her attitude reported by Resident 10. I called ADON after I talked to CNA F, but did not do an investigation. Yes, I told the resident I would, but I just told ADON. No, I did not fax to California Department of Public Health (CDPH), I did not do anything else. No, I did not take CNA F off the schedule, I was told to talk to her and remove her from Resident 10's room and I did. I don't know the entire policy for abuse, but I will get you a copy. During an interview on 02/14/23 at 3:42 pm with ADON and LN A. ADON stated, I vaguely remember. I cannot remember all the details, but I I told LN A to take CNA F out of Resident 10's room, find out what was said, if she was hurt, or harmed in any way. I follow up the next day, No I did not follow up the next day. No, I did not document, they report to administrator on call, it would have been 2/2/23 the last day she was in her room. It should be documented under the notes under the date the incident occurred. I do not recall the abuse policy. I do not see it here; I don't see any complaints recorded in stand-up. Oh, I did not do stand-up on the third of February. During a follow interview on 02/15/23 at 7:38 am, with ADON, stated, The administrator called CNA F yesterday at 6:30 pm and took her off the schedule, she was upset but understandable. CNA F will be off the schedule until we finish our investigation. As far as LN A reporting to me, she did call me and update me that Resident 10 was upset, she did not call me back with an update. The next morning I went to LN A and she stated there was no harm. It is my fault, I did not follow up. From now on, I will go directly to the resident and document. Abuse training is completed by the Director of Staff Development, (DSD), yes we can get CNA F's records of her abuse training. I do know Resident 10 keeps the port-a-cath tubing in her gown, so she could get upset related to the site. That may be why she was upset about the way the CNA F changed her gown. During an interview on 02/15/23 at 08:15 am, the DSD stated, I stepped into this role in December 2022, the last abuse training was I think October 2022. It is completed annually and with all new employees. There is a video and a post test. I do not know the specific policy or the steps if abuse occurs. I had no discussion or involvement with Resident 10, no direct oversight. I supervise the CNAs but did not know about this incident. I would pull her in the office, provide additional education, coaching or a performance. Example documentation, not physical abuse. Provided a copy of the test. No, we do not keep attendance logs for abuse training, its a video from California Department of Public Health, (CDPH) just dates the training was completed for each employee. During an interview on 02/15/23 at 11:55 am, the Chief Clinical Officer, (CCO) confirmed, We need more training on abuse, we will schedule in-services. We realize our weakness is education but will start working on it. I really wish I would have known sooner about Resident 10, I only found out yesterday, but I am working on my investigation. I am asking other residents about CNA F; Human Resources likes us to call it administrative leave. CNA F did admit she did not fix her pads under Resident 10, and did not go back to re-position resident, she did not state to me she told the Resident Oh well, she stated to me she told the resident You are okay. She also admitted she accidently pulled her gown at her access, but apologized to Resident 10. During an interview on 2/17/23 at 8:59 am, the Director of Quality and Risk Management, (DQRM) stated, I have only had to follow up with one allegation, and she was found not guilty of the allegations. I am going to start with orientation for all new employees when they are hired and spend a lot more time on the different types of abuse, discuss and educate with more in-services. This has been a learning lesson, I will go straight to the CCO with allegations, send the employee home, help with a complete investigation. The employee will not come back until we have completed a thorough investigation. The staff needs more education, and we will complete training more than once a year. Our process will be timely to stay in compliance. During an interview on 2/17/23 at 3:15 pm, Resident 10's Resident Representative, (RR) stated, I am so happy you are listening and helping her. I have been worried and it is hard for me to get out due to needing a new wheel chair. I believe her and she told me she was abused, I hope they can resolve this, it has upset me that they do not treat her right. I know they single her out, but I cannot understand why. She was in the Navy, Resident 10 deserves better than this. Please keep me updated, and I will keep checking on Resident 10. 2. A review of Resident 21's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a fall with fracture to the lumbar region, (break in the continuity of the bone to lower back), fracture of left arm and high blood pressure. A review of the most recent MDS dated [DATE] indicated that Resident 21 was cognitively intact (able to think and reason) and required extensive assistance with transferring from bed and toileting. A record review dated 2/15/23 titled, Resident 10 Complaint Investigation indicated Resident 21 was interviewed by the CCO and no time was documented. Interview from Resident 21 stated Yes, I know CNA F, she is immature. She walks in the room with her shoulders slumped over and calls me [NAME], hun, or sweety which I don't like. When she repositions me she could be gentler, it's like tugging instead of rolling. I know Resident 10 asks for a lot, but CNA F could have a better attitude. During an interview on 02/14/23 at 12:02 pm, Resident 21 stated, I worry about my roommate, they do not treat her right. It hurts me the difference in the way they treat me and my roommate. They single her out for some reason, I remember Resident 10 reporting CNA F. I agree with everything she said, it is the truth. During a follow interview on 2/15/23 at 10:22 am, Resident 21 stated, They took me to the nurses' station this morning for an interview, it was with CNA A and CCO. They asked me if I recognized CNA F, they showed a picture of her, and I did recognize her. They wanted to know how she treats me, and I told them. There were times I was not feeling good, I had a broken L1, she was kind of rough rolling me, condescending called me sweetheart, sweetie, and hun. I like to be called by my first name or even if she said my full name, I would be okay with that. I am a grown woman with my mind, who wants to be called those childish names. CNA F was using baby talk, it was obvious she did not like her job. For instance, using the bed pan, I cannot get up without braces, she was not happy if you need the bed pan, especially if you need to have a bowel movement. She needs to find something else to do, some people are just not cut out for it. She needs compassion. I told them I heard CNA F being rude to Resident 10. CNA F was rude, just rude and has an attitude. I am so happy they came to get me and asked me; I want them to know how CNA F treats us and hopefully they will do something about it. During an interview on 2/15/23 at 11:55 am, the CCO confirmed Resident 21 did state during her investigation of CNA F was demeaning to her calling her Sweetheart, Sweetie, Honey, etc. and Resident 21 did not like to be called names other than her first name. During an interview with CCO on 2/16/23 at 03:10 pm, CCO confirmed using nicknames and not preferred names is a part of resident rights and dignity for all residents. The staff should use the preferred name requested by the resident. The CCO also confirmed these nicknames could be condescending to the resident and any attitude would be considered a type of abuse. During an interview on 02/17/23 07:44 AM, the DQRM, stated Yes, all the nicknames for Resident 21 are not appropriate, it is a type of abuse if the residents do not like it and have stated they do not prefer nicknames. I am very affectionate, but I have to remember in this setting we cannot use those terms. I was a respiratory therapist but do understand attitudes and behaviors. It is not ok. I work in between upstairs and down here on the skilled unit and all the residents need to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility staff recognized and reported allegations of abuse/neglect for two of six sampled residents (Residents 10 and Resident 21). This failure put all residents at risk for abuse/neglect and injuries which had the potential to result in negative clinical outcomes by not removing the alleged employee from the schedule immediately, and not reporting the alleged abuse within 24 hours. Findings: 1. During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. Any employee that observes, or receives a report of abuse, or sees signs of abuse is legally required to report the alleged or suspected abuse to the California Department of Public Health, (CDPH) immediately or within 24 hours including weekends and holidays. The Chief Executive Officer (CEO) or designated administrator can make the required reporting to CDPH followed by a written report of completed investigation within 5 days. The administrator must notify local law enforcement of a report or observation of abuse, suspected abuse that may constitute a crime. The Ombudsman's office is also to be notified as appropriate to the alleged/suspected abuse. Employees alleged or suspected of having mistreated a resident will be removed from patient care immediately to protect residents from the potential of further harm and to assure safeguarding of the investigation process. The employee will need to complete all aspects of documentation and then must leave and remain out of the building until the completion of the investigation. 1. A review of Resident 10's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a spinal cord injury, Lupus, (a progressive disease that occurs when your body's immune system attacks your own tissues and organs that can affect all organs in the body) and suprapubic catheter, a urinary catheter that drains urine directly from the bladder, and diabetes. A review of the most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/10/22 indicated that Resident 10 was cognitively intact (able to think and reason) and required extensive assistance and is totally dependent on staff for all activities of daily living. During an interview on 2/14/23 at 11:19 am, Resident 10 stated, I am having a problem with a Certified Nursing Assistant (CNA). CNA F is rude and always has an attitude. CNA F left me uncomfortable, and refused to move my incontinent pad under me, it was up to my neck. When I asked CNA F to reposition the incontinent pad under me, she walked off and stated, You are fine. Oh, well. My roommate heard her too. CNA F was in a hurry when she was changing my gown and pulled at my port-a-cath access, (IV access to administer medications). She needs more training; she needs to slow down. I reported all of this to Licensed Nurse, (LN) A and told her CNA F needs more training. She was supposed to do an investigation and let me know the results. I never heard back from LN A about it, or anyone, but CNA F has been taken off my room schedule. I have not seen CNA F, but I would like an update. It has been a week or two since I reported it to LN A. I told LN A I was afraid of retaliation, and she told me she would keep it in confidence. They have put me in a depression, it has been so hard, I felt like I was in trouble. During an interview on 02/14/23 at 12:02 pm, Resident 21 stated, I worry about my roommate, they do not treat her right. It hurts me the difference in the way they treat me and my roommate. They single her out for some reason, I remember Resident 10 reporting CNA F. I agree with everything she said, it is the truth. During an interview on 02/14/23 at 3:18 pm, LN A stated, I do remember Resident 10 complaining about CNA F, LN D updated me there was a complaint. I talked to Resident 10 on 2/2/23. No, I did not document in Resident 10's record, I know I should have, but I did not make any notes or documentation. Yes, I told the resident I would do an investigation, but I just told the Assisted Director of Nursing, (ADON), I did not follow up with Resident 10. No, I did not fax to CDPH, I did not do anything else. No, I did not take CNA F off the schedule, I was told to talk to her and remove her from Resident 10's room and I did. I don't know the entire policy for abuse, but I will get you a copy. During an interview on 02/14/23 at 3:42 pm, ADON stated, No, I did not document, the staff should report to administrator on call, it would have been 2/2/23 the last day CNA F was in Resident 10's room. I do not recall the abuse policy. During a follow up interview on 02/15/23 at 7:38 am, with ADON, stated The administrator called CNA F yesterday at 6:30 pm and took her off the schedule, she was upset but understandable. CNA F will be off the schedule until we finish our investigation. During an interview on 02/15/23 at 08:15 am, Director of staff Development, (DSD) stated, The abuse training is completed annually and with all new employees. I do not know the specific policy or the steps if abuse occurs, or the steps of reporting the alleged abuse. A record dated 2/15/23 a initial report titled, Preliminary Investigation Results, completed by the Chief Clinical Officer (CCO) dated 2/15/23 indicated this report was faxed to CDPH and Ombudsman on 2/15/23 at 7:33 am, for Resident 10's allegation against CNA F, 13 days later than Resident 10 reported the alleged abuse to two separate licensed nurses. 2. A review of Resident 21's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a history of falling, fall with fracture to the lumbar region, (L1, lower back), fracture of left arm, and hypertension. A review of the most recent MDS dated [DATE], indicated that Resident 21 was cognitively intact (able to think and reason) and required extensive assistance with transferring from bed and toileting. A record review of Resident 21's progress notes had no documentation of any complaints, interviews, or faxing an investigation related to names called by CNA F from 2/14/23 to 2/17/23 that were demeaning, such as sweetie, hun, sweetheart. A record review dated 2/15/23 titled, Resident 10 Complaint Investigation indicated Resident 21 was interviewed by CCO and no time was documented. Interview from Resident 21 stated, Yes, I know CNA F, she is immature. She walks in the room with her shoulders slumped over and calls me [NAME], hun, or sweety which I don't like. When she repositions me she could be gentler, it's like tugging instead of rolling. I know Resident 10 asks for a lot, but CNA F could have a better attitude. During a follow up interview on 2/15/23 at 10:22 am, Resident 21 stated, They took me to the nurses' station this morning for an interview, it was with CNA A and CCO. They asked me if I recognized CNA F they showed a picture of her, and I did recognize her. They wanted to know how she treats me, and I told them. There were times I was not feeling good, I had a broken L1, she was kind of rough rolling me, condescending called me sweetheart, sweetie, and hun. I like to be called by my first name or even if she said my full name, I would be okay with that. I am a grown woman with my mind, who wants to be called those childish names. CNA F was using baby talk, it was obvious she did not like her job. For instance, using the bed pan, I cannot get up without braces, she was not happy if you have a bowel movement. CNA F needs to find something else to do, some people are just not cut out for it. She needs compassion. I told them I heard CNA F being rude to Resident 10. CNA F was rude, just rude and has an attitude. I am so happy they came to get me and asked me; I want them to know how CNA F treats us and hopefully they will do something about it. During an interview on 02/15/23 at 11:55 am, the CCO stated, I really wish I would have known sooner about Resident 10, I only found out yesterday, but I am working on my investigation of CNA F. Human Resources likes us to call it administrative leave, CNA F has been removed from the schedule as of 2/14/23 at 6:30 pm. CCO also confirmed the five day follow up investigation would be late to CDPH related to the delay in reporting the alleged abuse by Resident 10 on 2/2/23 and moving forward she would educate staff about the the reporting guidelines and will report within the 2 or 24 hours as required. During an interview on 2/17/23 at 8:59 am, the Director Quality & Risk Management (DQRM) and designated Abuse Coordinator stated, I am going to start with orientation for all new employees when they are hired and spend a lot more time on the different types of abuse, discuss and educate with more in-services. This has been a learning lesson, I will go straight to the CCO with allegations, send the employee home, help with a complete investigation. The employee will not come back until we have completed a thorough investigation. The staff needs more education, and we will complete training more than once a year. Our process will be timely to stay in compliance for reporting alleged abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure allegations of abuse/neglect and were thoroughly investigated, staff was trained to take corrective actions to prevent further abuse for two of six sampled residents (Residents 10 and Resident 21). These failures had the potential for ongoing alleged verbal and physical abuse which could lead to many negative outcomes. Findings: During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. The facility recognizes and supports the laws, rules, and regulations that require all employees to report incidents of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property to the administrator of the facility, and to other officials in accordance to state law. The four components are abuse prevention procedures, abuse reporting and investigation procedures, findings and response, and documentation. Section two of this policy is tiltled Abuse Reporting and Investigating Procedures indicated any employee that observes any type of abuse, is told by a resident that he/she has been abused should immediately notify their supervisor and the CEO (Chief Executive Officer) or designated administrator. 1. A review of Resident 10's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a spinal cord injury, Lupus, (a progressive disease that occurs when your body's immune system attacks your own tissues and organs that can affect all organs in the body) and suprapubic catheter, a urinary catheter that drains urine directly from the bladder, and diabetes. A review of the most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/10/22 indicated that Resident 10 was cognitively intact (able to think and reason) and required extensive assistance and is totally dependent on staff for all activities of daily living. During an interview on 2/14/23 at 11:19 am, Resident 10 stated, I am having a problem with a Certified Nursing Assistant (CNA). CNA F is rude and always has an attitude. CNA F left me uncomfortable, and refused to move my incontinent pad under me, it was up to my neck. When I asked CNA F to reposition the incontinent pad under me, she walked off and stated, You are fine. Oh, well. My roommate heard her too. CNA F was in a hurry when she was changing my gown and pulled at my port-a-cath access, (surgical access to administer Intravenous medications). She needs more training; she needs to slow down. I reported all of this to Licensed Nurse (LN) A and told her CNA F needs more training. She was supposed to do an investigation and let me know the results. I never heard back from LN A about it, or anyone, but CNA F has been taken off my room schedule. I have not seen CNA F, but I would like an update. It has been a week or two since I reported it to LN A. I told LN A I was afraid of retaliation, and she told me she would keep it in confidence. They have put me in a depression, it has been so hard, I felt like I was in trouble. During an interview on 02/14/23 at 3:18 pm, LN A stated, I do remember Resident 10 complaining about CNA F, LN D updated me there was a complaint. I talked to Resident 10 on 2/2/23, I called the Assistant Director of Nursing, (ADON), she had already gone home, she was not here in the facility after I talked to Resident 10 about her concerns of CNA F. No, I did not document in Resident 10's record, I know I should have, but I did not make any notes or documentation. Yes, I told the resident I would do an investigation, but I just told ADON. I did not follow up with Resident 10. No, I did not fax to California Department of Public Health (CDPH), I did not do anything else. No, I did not take CNA F off the schedule, I was told to talk to her and remove her from Resident 10's room and I did. I don't know the entire policy for abuse, but I will get you a copy. A record dated 2/15/23 an initial report titled, Preliminary Investigation Results, completed by the Chief Clinical Officer, (CCO) dated 2/15/23 indicated this report was faxed to CDPH and Ombudsman on 2/15/23 at 7:33 am, for Resident 10's allegation against CNA F, 13 days later than Resident 10 reported the alleged abuse. 2. A review of Resident 21's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included a fall with fracture to the lumbar region, (L 1,break in the bone in the lower back), fracture of left arm, and high blood pressure. A review of the most recent MDS dated [DATE], indicated that Resident 21 was cognitively intact (able to think and reason) and required extensive assistance with transferring from bed and toileting. During an interview on 02/14/23 at 12:02 pm, Resident 21 stated, I worry about my roommate, they do not treat her right. It hurts me the difference in the way they treat me and my roommate. They single her out for some reason, I remember Resident 10 reporting CNA F. I agree with everything she said, it is the truth. During a follow up interview on 2/15/23 at 10:22 am, Resident 21 stated, They took me to the nurses' station this morning for an interview, it was with CNA A and CCO. They asked me if I recognized CNA F, they showed a picture of her, and I did recognize her. They wanted to know how she treats me, and I told them. There were times I was not feeling good, I had a broken L1, she was kind of rough rolling me, condescending called me sweetheart, sweetie, and hun. I like to be called by my first name or even if she said my full name, I would be okay with that. I am a grown woman with my mind, who wants to be called those childish names. CNA F was using baby talk, it was obvious she did not like her job. For instance, using the bed pan, I cannot get up without braces, she was not happy if you need the bed pan, especially if you need to have a bowel movement. She needs to find something else to do, some people are just not cut out for it. She needs compassion. I told them I heard CNA F being rude to Resident 10. CNA F was rude, just rude and has an attitude. I am so happy they came to get me and asked me; I want them to know how CNA F treats us and hopefully they will do something about it. A record review dated 2/15/23 titled, Resident 10 Complaint Investigation indicated Resident 21 was interviewed by the CCO and no time was documented. Interview from Resident 21 stated, Yes, I know CNA F, she is immature. She walks in the room with her shoulders slumped over and calls me [NAME], hun, or sweety which I don't like. When she repositions me she could be gentler, it's like tugging instead of rolling. I know Resident 10 asks for a lot, but CNA F could have a better attitude. During an interview on 02/15/23 at 11:55 am, the CCO confirmed more training and education was needed for their abuse policy and procedures. All staff should know who to report alleged abuse to, how to complete a thorough investigation, and how to complete an investigation, including documentation of interviews and updating the abuse coordinator. CCO also confirmed all employees need to follow their own abuse policy and procedures for all residents. During an interview on 2/17/23 at 8:59 am, the Director of Quality & Risk Management (DQRM) and designated Abuse Coordinator stated, I am going to start with orientation for all new employees when they are hired and spend a lot more time on the different types of abuse, discuss and educate with more in-services. This has been a learning lesson, I will go straight to the CCO with allegations, send the employee home, help with a complete investigation. The employee will not come back until we have completed a thorough investigation. The staff needs more education, and we will complete training more than once a year. Our process will be timely to stay in compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure competent nursing staff for 16 of 16 residents sampled when: 1. The facility staff did not understand the different types of resident abuse and the abuse policy process which would include 16 of 16 sampled residents. This failure to ensure competent staff for facility's abuse process did result in alleged abuse not being reported to California Department of Public Health (CDPH). 2. Two licensed nurses (LNs) did not administer three separate inhalers correctly for Resident 133 and Resident 18, per professional standards of practice for two of sixteen sampled residents. This failure for licensed nurses to omit education, demonstration, verbal cues had the potential for Resident 13 and Resident 18 to not receive therapeutic effect of medications ordered. 3. Three of three nurses did not check therapeutic diet orders for 16 of 16 sampled residents before the Certified Nursing Assistants (CNAs) passed the meal trays. This failure to ensure competent nurses to check diet orders had the potential to cause allergic reactions, swallowing problems, and a decline in physical well-being for all residents. Findings: 1. During a review of a policy revised 1/2023, titled, Abuse Prevention And Management: Transitional Care Unit, (TCU), indicated The purpose of this policy is to define the policies and procedures of Vibra Hospital of Northern California, (VHNC) that have been developed to prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property, manage situations, and conduct investigations when there is an allegation or a finding of abuse. VHNC recognizes and supports the laws, rules, and regulations that require all employees to report incidents of mistreatment, neglect or abuse, injuries of unknown source and misappropriation of resident property to the administrator of the facility, and to other officials in accordance to state law. This policy addresses the four key components of a comprehensive abuse prevention program. The four components are abuse prevention procedures, abuse reporting and investigation procedures, findings and response, and documentation. The facility's policy revised 01/2023, titled, Promoting/Maintaining Resident Dignity, was reviewed, and indicated the purpose of this policy is to protect and promote resident rights, and treat each resident with respect and dignity as well as care for each resident in a manner that maintains or enhances resident's quality of life by recognizing each resident's individuality. This policy indicated the resident's personal choices will be considered when providing care and services, respond to requests for assistance in a timely manner, speak respectfully to residents, and each resident will be provided equal access to quality care regardless of a diagnosis, severity of condition, or payment source. During a review of a document titled, Elder Abuse Training, indicated CNA F completed Elder Abuse Training on 12/13/22. This record also indicated 31 other employees had completed Elder Abuse Training from 3/5/22 through 2/16/23. 10 of 31 employees, (the Director of Quality Management, (DQM), Assisted Director of Nursing, (ADON), Activities Director, (AD), Director of Staff Development (DSD), CNA A, CNA B, CNA C, DSD, LN A, and LN D were not able to verbalize the abuse policy or steps to report when interviewed from 2/14/23 through 2/17/23. During an interview on 02/14/23 at 3:18 pm, LN A stated, I called the ADON, she had already gone home, she was not here in the facility after I talked to Resident 10 about her concerns of CNA F. The ADON had me to talk to CNA F, I wasn't sure if it was accidental or on purpose when Resident 10 described CNA F did not give her assistance with repositioning and the incontinence pads were way too high, leaving Resident 10 uncomfortable. Yes, I did talk to CNA F about her attitude and incontinence pad placement reported by Resident 10. I called ADON after I talked to CNA F, but did not do an investigation. No, I did not document in Resident 10's record, I know I should have, but I did not make any notes or documentation. Yes, I told the resident I would do an investigation, but I just told ADON. I did not follow up with Resident 10. No, I did not fax to CDPH, I did not do anything else. No, I did not take CNA F off the schedule, I was told to talk to her and remove her from Resident 10's room and I did. I don't know the entire policy for abuse, but I will get you a copy. During an interview on 02/14/23 at 3:42 pm with ADON and LN A, ADON stated, I follow up the next day, No I did not follow up the next day. No, I did not document, the staff should report to administrator on call, it would have been 2/2/23 the last day CNA F was in Resident 10's room. Documentation should be present for Resident 10 in the notes under the date the complaint occurred. I do not recall the abuse policy. During an interview on 02/15/23 at 08:15 am, DSD stated, I stepped into this role in December 2022, the last abuse training was I think October 2022. It is completed annually and with all new employees. There is a video and a post test. I do not know the specific policy or the steps if abuse occurs, I have been a nurse almost three years now. During an interview on 02/15/23 at 09:53 am, CNA A stated, I have been a CNA for five years now. They generally wait to see what the allegation is. Abuse coordinator, I do not know who that is. Abuse is like a text message; you can interpret different ways. No, I did not know they send you home for verbal, I thought they send you home for physical only. During an interview on 02/15/23 10:50 am, CNA D stated, I have been here 3 months, I am not sure about the policy, I know abuse is physical, emotional, verbal. We report it to a nurse or charge nurse, they update the Ombudsman. Uh, I am not sure what they do? If someone is accused of verbal abuse, I assume they give them a day off, I do not know, but I will find out. I do not know who the abuse coordinator is, but I will find out. During an interview on 02/15/23 at 11:10 am, CNA C stated, I have been a CNA for 6 years now. I know we are all mandatory reporters. I know to report to the nurse on charge nurse. I do not know the policy; I do not know what happens to the employee. I do not know the abuse process. During an interview on 02/15/23 at 11:34 am, the AD stated, I have one employee, the abuse coordinator is the DQM. We would report it to a nurse or charge nurse. I do not know what happens, I don't know the policy, I will find out, we don't really see that much. During an interview on 2/17/23 at 8:59 am, the DQM and designated Abuse Coordinator stated, I have only had to follow up with one allegation, and she was found not guilty of the allegations. I am going to start with orientation for all new employees when they are hired and spend a lot more time on the different types of abuse, discuss and educate with more in-services. This has been a learning lesson, I will go straight to the Chief Clinical Officer (CCO) with allegations, send the employee home, help with a complete investigation. The employee will not come back until we have completed a thorough investigation. The staff needs more education, and we will complete training more than once a year. Our process will be timely to stay in compliance. 2. A) During a review of a policy revised 1/2022, titled, Administration of Medications, indicated only licensed nursing personnel, (Registered Nurse, Licensed Vocational Nurse) and other health professionals in acccordance with state regulations and medical staff approval may administer medications. A review of the policy titled, Procedure, indicated section four, follow preparation directions, (e.g Do Not Crush, give with water, etc.). A review of Resident 133's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included pneumonia, (infection of one or both lungs) and acute respiratory failure, (when lungs cannot release enough oxygen in the blood) and history of recent Covid19. A review of the most recent Minimum Data Set (MDS, a standardized resident assessment) dated 2/14/23 indicated that Resident 133 was cognitively intact (able to think and reason) and required extensive assistance and was totally dependent on staff for all activities of daily living. During a record review of Resident 133's physician orders dated 2/16/23, titled, Medication Administration Record, indicated an order for a medication to treat asthma, Mometasone/Formoterol (Dulera) 200/5 Micrograms, (mcg,a unit of measure) inhale 2 puffs two times daily, (BID). During a record review of Resident 133's physician orders dated 2/16/23, titled, Medication Administration Record, indicated an order for a medication, Tiotropium Bromide (Spiriva) 2.5 mcg inhale 2 puffs daily for lung disease. During an observation on 2/16/23 at 8:32 am, LN B administered two separate inhalers (Dulera and Spiriva) ordered for Resident 133 with no verbal cues or instructions for use. Per manufacturer's instructions for use, LN B did not properly administer inhaler Mometasone/Formoterol (Dulera) 200/5 Micrograms to Resident 133. Instructions indicate, thirteen steps for proper administration. Three of the thirteen steps were not followed for Resident 133. Step seven indicated to Breathe out as fully as you comfortably can through your mouth, push out as much air from your lungs as possible. Step eight indicated to take a deep breath in slowly, through your mouth. While doing this, push canister, step nine indicated when you have fully breathed in, then hold your breath as long as you can, up to 10 seconds. Per manufacturer's instructions for use, LN B did not properly administer inhaler Tiotropium Bromide (Spiriva) 2.5 mcg for Resident 133. Per instructions for use there are five separate steps to use Spiriva inhaler properly. Step 4 was omitted for Resident 133 when instructions or verbal cues were not provided to complete step four-Breathe out completely for one breath, emptying your lungs of any air. Holding inhaler, breathe in deeply until your lungs are full, you should hear or feel the spirva capsule vibrate. Hold your breath for a few seconds, and at the same time, take your inhaler out of your mouth. Breathe normally again. REMEMBER: To get your full Spiriva dose each day, you must breathe in two times from the same capsule. Make sure you breathe out completely each time before you breathe in from your inhaler device. During an interview on 2/16/23 at 8:40 am, LN B stated, I don't know how long in between inhalers, is it three minutes or five minutes? I don't know what to tell the resident. I don't know which one is supposed to be first. No, I did not instruct Resident 18 how to breathe before administration. I did not provide any directions or verbal cues. During an interview on 2/16/23 at 8:50 am, LN A confirmed Yes, Per manufacturer's instructions and all inhalers you allow the resident to breathe out first and should provide instructions or education if resident needs it. B) A review of Resident 18's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included ileostomy, (the small intestine is diverted through an opening in the abdomen), decreased appetite, and history of Covid19. A review of the most recent MDS dated [DATE], indicated that Resident 18 was cognitively intact (able to think and reason) and required extensive assistance and was totally dependent on staff for all activities of daily living. During a record review of Resident 18's physician orders dated 2/16/23, titled, Medication Administration Record, indicated Trelegy Ellipta (treatment for lung disease) 100-62.5-25 micrograms, (mcg, a unit of measure) MCG/INH ordered Inhale 1 puff daily, rinse mouth after use. Observation on 2/16/23 at 9:22 am, LN C administered the inhaler Trelegy Ellipta 100-62.5-25 mcgs, Inhale 1 puff daily without providing instructions to Resident 18 for proper administration per manufactuer's directions, nursing standards of practice for correct administration for an inhaler. Per manufacturer's instructions for this inhaler, indicated, Step 2- Breathe out, Step 3- take in one steady breath through your mouth, do not breathe in through the nose, hold your breath 3-4 seconds Step 4-Breathe out slowly and gently. Steps 2, 3 and 4 were omitted for this medication administered for Resident 18. During an interview on 2/16/23 at 9:35 am, LN C stated, No, I did not know to give instructions for an inhaler. After LN C researched the specific inhaler ordered for Resident 18 on her phone she agreed and stated, I know now, and I will teach these steps from now on. 3. During a review of a policy revised 1/23, titled, Serving a Meal, indicated the purpose of this policy is to serve meals that meet the nutritional needs of residents in a safe environment that enhances the resident's quality of life. This policy indicated, It is this policy of this facility to serve nutritionally substantive meals that are palatable and attractive in a safe environment that enhances the resident's quality of life. Section one indicated, Diets should be served in accordance with physician's orders which can only be checked by the nurses with access for administering medications and treatments once the food tray is delivered on the halls. During a review of Treatment Administration Records, (TAR) dated 2/1/23 through 2/28/23 for sixteen residents, the following order was indicated for all sixteen residents, Diet every shift and is signed in the electronic medical record every shift by the nurses for each meal, for two separate shifts. Each resident has their specific physician ordered diet documented on the TARs. During an interview on 2/16/23 at 8:35 am, LN D stated, No, I never check the diet order with the trays before they pass them out, I did not know I was supposed to. No one ever told me, but I will from now on. During an interview on 02/16/23 at 9:04 am, LN B stated, I do not check the trays before they pass them, I asked when I was hired in June because other facilities do, but they said I do not need to check the diet orders. No, I do not remember who told me that. I check some when I help pass trays, but not regularly. No, I did not this morning or yesterday, usually once a week. During an interview on 2/16/23 at 9:10 am, LN C stated, I will be honest, I do not check the trays before the staff passes out the trays. I do check once I go in the rooms while I am passing medications. Yes, they are already eating their trays by the time I get in the rooms. I know technically we are supposed to check all the diet orders for safety related to texture and allergies. During an interview on 2/16/23 at 9:15 am, LN A stated, I am going to tell you the truth, I am confirming all nurses should check all diet orders with the meal trays for all meals before the trays are passed out to the residents for safety, it is an order, and it is recorded on the TARs. The texture, liquids, allergies, and all parts of the dietary order should be checked. During an interview on 2/16/23 at 3:50 pm, the ADON confirmed all diet orders should be checked by the nurses before meal trays are given to the residents.

Based on observation, interview and record review, the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: 1. The food cooling process was not completed consistently or correctly. 2. Produce wash was not tested or used according to manufacturer's instructions. 3. Equipment was not cleaned according to professional standards of practice. 4. Gloves were not changed between tasks to prevent cross contamination. 5. Foods were not consistently labeled and dated. 6. Recipes were not followed. These failures had the potential to result in foodborne illness and decreased meal intakes for all residents receiving meals from the facility. Findings: 1. The food cooling process for Time Temperature Control for Food Safety (TCS) foods was not completed consistently or correctly according to professional standards of practice or facility policy (Cross Reference F812, F801). During an observation in the walk-in refrigerator on 2/14/23 at 10:38 am, cooked pork dated 2/12/23 and cooked pasta dated 2/13/23 were on the shelf. During an interview with [NAME] B on 2/15/23 at 9:50 am, he stated hot food must be cooled from 40 degrees Fahrenheit (°F) to 140°F within 4 hours. During a concurrent review of the Cooling Temperature Log dated February 2023, [NAME] B indicated the two entries on the log were incorrect because they did not have a starting temperature. During an observation on 2/15/23 at 9:50 am the café refrigerator contained a pan of egg salad dated 2/13/23. In a concurrent interview Dietary Aide B (DA B) stated they made egg salad and chicken salad for the cafeteria but would provide egg salad for residents if requested. During an interview on 2/15/23 10:05 am, DA B stated her ingredients for egg salad were usually from the refrigerator. She stated if she was making tuna salad, the tuna would be at room temperature because it would come from the shelf in dry storage. DA B stated she only checked the temperature for egg salad used in the café. Later she stated she checked the egg salad temperature before she made sandwiches for residents and it was usually around 31°F, but she didn't write it down anywhere. Review of a document titled, Cooling Temperature Log, dated February 2023, showed the pork cooling log was not completed in accordance with the two-step professional standard of practice for food safety. There was no start temperature greater than 135°F, and the first temperature documented was 80°F. There was no cooling log for the cooked pasta or egg salad. Further review of five monthly cooling logs dated October 2022 through February 2023 showed seven out of seven entries were performed incorrectly. Review of a policy titled, Employee Sanitation Practice, dated 4/19, described the two-step process for food safety. Review of the 2022 FDA Food Code 3-501.14 described the two-step cooling process for food safety for both hot and ambient temperature foods. 2. Produce wash was not tested or used according to manufacturer's instructions. Review of a policy titled, Employee Sanitation Practices, revised 04/2019, showed To prevent chemical food poisoning: all fresh fruits and vegetables are washed thoroughly before preparation and/or service. During an observation and concurrent interviews on 2/14/23 at 10:49 am, DA A explained they used an Antibacterial Fruit & Vegetable Wash to clean their produce. The process she described did not match the manufacturer's instructions, and she was unaware of any time frame the produce needed to soak in the wash product for it to be effective. In addition, DA A stated she was unaware the pH (a measure of how acidic or basic a substance or solution is) of the wash product was ever checked to ensure it was at the correct level for food safety and effectiveness, and she had not been trained to do that. In a concurrent interview, [NAME] G stated he had never tested the vegetable wash. During further interview the DM stated the testing was not assigned to any specific position, and he was unable to find test strips in the work area. Review of training checklists titled, Core Competency/Demonstration Cook, and Core Competency/Demonstration Dietary Aide/Dishwasher, did not indicate staff were trained and competent in testing and use of vegetable wash. 3. Equipment was not cleaned according to professional standards of practice (Cross Reference F812, F801). During observations between 2/14/23 at 9:57 am and 2/17/23 at 12 pm, kitchen equipment including ovens, blender, robo coup, can opener, and carts were not clean. During an interview on 2/16/23 at 2:20 pm the DM stated when cleaning fixed equipment, staff should use hot soapy water, then rinse, then sanitize. Three out of three staff (Cook D, [NAME] F, Dietary Aide B (DA B) interviewed during the survey reported only using sanitizer to clean equipment (Cross Reference F812). The facility did not provide a policy that would direct staff regarding the general process for cleaning all fixed equipment (equipment that cannot go through the dishwasher or manual ware-washing sink). Review of the 2022 FDA Food Code 4-603.15 and 4-603.16 describe a distinct 3-step wash, rinse and sanitize process for fixed equipment. 4. Gloves were not changed between tasks to prevent cross contamination (Cross Reference F812, F801). Review of the facility provided policy titled, Employee Sanitation Practices, revised 4/2019, showed Hand Hygiene, should be done .After handling soiled equipment or utensils .During food preparation, as often as necessary to remove soil and contamination and prevent cross- contamination when changing tasks and .before donning gloves to initiate a task that involves working with food. During observations of lunch tray line (meal tray assembly process) between 2/15/23 at 11:42 am and 2/15/23 at 11:47 am, [NAME] A, DA B, and the Meal Planner (MP) touched unclean surfaces with their gloves on and did not wash hands or change gloves before returning to touching food and utensils on tray line. During interviews with the DM on 2/16/23 at 2:20 pm, and with the RD on 2/16/23 at 3:03 pm they stated gloves should be changed when changing tasks. 5. Foods were not consistently labeled and dated (Cross Reference F812, F801). Review of the 2022 FDA Food Code 3-501.17, showed Refrigerated, ready-to-eat, time/temperature control for food safety food .shall be clearly marked to indicate the date or day by which the food shall be consumed .sold or discarded when held at a temperature of 41° or less for a maximum of 7 days. During an observation in the walk-in refrigerator on 2/14/23 at 10:38 am a plastic container of hard-cooked eggs was not labeled or dated. During an interview with DA B on 2/17/23 at 10:25 am, she stated Everything should be labeled, and the label should include what the item is, and the date it was put in the refrigerator. She stated staff should also put the expiration date on it, but not everyone does that. During an interview with the DM on 2/16/23 at 2:20 pm, he stated labeling and dating should include what the food it is, and the date it was placed in that container. He further stated a lot of staff didn't take the time to put the use-by date on the label, but they used their food storage guidelines to figure it out. 6. Recipes were not followed (Cross Reference F804, F806). During a concurrent test tray study and interview on 2/16/23 at 12:04 pm, the DM agreed the black beans were bland, had no flavor, and needed seasoning. Review of a recipe titled, Black Beans SPD, from the cooks recipe book, and provided by the DM showed the black beans were to contain bay leaves, fresh thyme, parsley, onion, celery, carrots, green pepper, garlic, cumin, oregano, salt and pepper. During an interview with the DM on 2/16/23 at 2:20 pm he stated he wasn't sure there was a recipe for the black beans, they bought canned low sodium black beans, and the cook probably just opened the can. He stated cooks needed to remember to season the beans, but not with salt, and they needed to remember onion allergies. During an interview with [NAME] B on 2/17/23 at 10:15 am he showed black bean recipe in the cook's recipe book. He stated Most of the time I follow the recipes, but I was behind. When I have the can (of black beans), it's simpler and easier to use the can. A review of the label on the facility's black beans showed they were low sodium, with ingredients: black beans, water, salt, calcium chloride (firming agent). Review of twelve documents provided by the Dietary Manager (DM) titled, Dietary In-service Notes, dated 2/7/22 through 1/16/23 showed in-services included these topics: Keep work areas clean and tidy (the 3-step process for cleaning work areas - wash, rinse, sanitize - was not described) - 2/7/22. Covering, labeling and dating food correctly (the labeling criteria was not described) - 4/22/22, 10/5/22, Hot food must be cooled correctly and entered into the cool down log (ambient food was not mentioned) - 4/22/22. Food carts must be wiped down with sanitizer after every meal and before next service. Inside and outside completely (The 3-step wash, rinse, sanitize process was not mentioned) - 6/29/22. Cooks must follow the menu and the recipe for menu items - 6/29/22. Glove use - Put on gloves for each project. Remove gloves, wash and dry hands, and put on new gloves - 1/16/23. Review of a policy titled, Orientation & Competency Assessment revised 10/18, reviewed 1/22 showed Food and Nutrition Services Staff participate in competency assessment validating knowledge and skills via testing and direct observation with competency outcomes documented .employees receive probationary and annual performance appraisals that are documented in employees Human Resources and Department files .Competency assessment is conducted .related to position-specific performance. Review of documents titled, Core Competency/Demonstration Cook, and Core Competency/Demonstration Dietary Aide, were provided by Human Resources for [NAME] A (4/15/19), Dietary Aide A (DA A) (4/15/19), DA B (4/12/19), [NAME] C (8/24/22, 11/10/20) and DM (4/15/19). They showed these staff were assessed and competent including topics: Infection Prevention (Hand hygiene, glove use), and Essential Functions (food preparation, prepares food according to hospital provided recipe, cleans and sanitizes work areas and equipment, stores and labels food). The lists did not specify training and competency in food cooling, food allergies, therapeutic diets, or how to access and use the facility-specific diet manual if they had questions about resident food. The competency of four out of five staff reviewed had not been reassessed in four years.

Based on observation, interview and document review, the facility failed to ensure meals met resident preferences as evidenced by complaints of cold food, palatability and food quality for 10 residents. (Residents 229, 230, 10, 21, 231, 9, 129, 18, 133 and 134) This failure had the potential to result in decreased meal intake, weight loss, resulting in compromised nutritional status. Findings: During an interview on 2/14/23 at 11 am, Resident 229 stated, she must eat what they brought her even if she didn't care for it. The food was usually cold, and tasteless. During an interview on 2/14/23 at 3:32 pm, Resident 230 stated, the food was not good and that substitutes were not offered. She stated she didn't know she could. Further stated, she just took what she got and it was usually cold. During an interview on 2/15/23 at 10:02 am, Resident 10 stated, the food was cold a lot . several times a week. During an interview on 2/15/23 at 10:15 am, Resident 21 stated, she have been to the facility since 12/17/22, and not being offered alternatives. She stated the grilled cheese was not cooked enough and a lot of times the food was cold. Often her husband brought food from home so that she can have something to eat. Resident 21 stated, she was a cook at a hospital, this was the worst food she'd ever had. She further stated, the toughest and driest meat no flavor, steamed vegetables were just mush, mixed garden peas, squash and cannot tell one from the other. The food was terrible. During an interview on 2/14/23 at 10:19 am, Resident 231 stated, things that were supposed to be hot were cold. Cold things were hot. During an interview on 2/15/23 at 8:13 am, Resident 18 stated she is sick of eggs and pointed to the egg remaining on her breakfast tray. That doesn't look very appetizing. During a review of the resident council meeting minutes dated 2/15/23 at 11 am, meal temperature and palatability were not maintained in accordance with resident facility expectations, when residents 9, 18, 21, 10, 129, 133, 134, complained about the temperature and the taste of the food served. In a confidential interview on 2/16/23 at 11:28 am, one of 4 residents stated the vegetables were too soggy or too hard, the meat was tough, and they didn't eat any of it. The grilled cheese was too tough, the crust was too hard. A record review of the 2/16/23 regular tray lunch menu consists of fajita marinated chicken 3 ounces, cheese sauce, black beans a half a cup, sauteed onions and peppers a half a cup, flour tortilla one each, margarine spread one each, ice cream one each, and garnish salsa one tablespoon, coffee or tea one cup. On 2/16/23 at 11:25 am, the meal staff were preparing the tray line for lunch. Then a test tray was conducted concurrently thereafter. At 11:31 am, the temperatures at the start of the meal service were as follows: Chicken fajita (chopped and regular) -152.4 degrees Fahrenheit (°F ) for the [NAME] A, 152.6 °F for the surveyor. Ground chicken temperatures- [NAME] A- 144 °F , surveyor 147 °F. On 2/16/23 at 11:51 am, the last tray was placed on dietary cart one for rooms 120 to 130. On 2/16/23 at 11:53 am cart number one arrived for rooms 120-130. The transporter opened the food cart door and left it open. On 2/16/23 an observation at 11:54 am, the first tray was taken off by Certified Nursing Assistant (CNA) H. There were not staff in the hallway to remove the remaining lunch trays from the cart. On 2/16/23 an observation at 12:02 pm, the 3rd meal tray was taken off the cart. On 2/16/23 an observation at 12:04 pm, the last tray was removed from the dietary cart. An observation of lunch meal test trays and concurrent interview with the Dietary Manager (DM) was conducted at 2/16/23 at 12:20 pm. Food temperatures taken by the DM and surveyor were as follows: Test tray (Regular) the temperature and flavor of the first test tray Test tray (Regular) Chicken dry -121.6 °F flavorful Beans -129°F, bland and cold. The second tray (mechanical soft/ground tray) evaluated by the DM's thermometer. ground fajita chicken fajita chicken -131°F, Fajita onions and Peppers 129°F , black beans- good texture and bland. The chicken texture was dry. Tested both the DM, RD and the surveyor. Record review of the document titled, Test Tray Evaluation Form, indicated the acceptable delivery temperature for the entrée is 135°F (Minimum) and the acceptable delivery temperature of the vegetable (minimum) is 135°F. A record review of the document titled, Employee Sanitation Practice,revised 04/19, indicated, food is prepared as quickly as possible, keeping holding time at room temperature to a minimum.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accommodate resident food allergies, preferences, and provide appealing alternate food options when: 1. An effective system was not in place to avoid resident's known food allergies, and the facility failed to check one of six sampled residents' diet orders and meal trays for accuracy and safety before delivering the meal tray, (Resident 10). 2. Two residents (Residents 128, 134) reported their food preferences were not honored. 3. Seven residents (Residents 18, 231, 229, 230, 21, 7, 14) reported a lack of choice or ability to access a selection of alternative meals. These failures resulted in Resident 10's allergic reaction to a known food allergy that required medication, and they had the potential to result in decreased nutrition intake, weight loss, decreased quality of life, and decline in medical status for all residents living in the facility. Findings: Review of a policy titled, Serving a Meal, revised 1/23, showed the purpose is to serve meals that meet the nutritional needs of residents in a safe environment that enhances the resident's quality of life The procedure directed, Diets should be served in accordance with physician's orders, but did not direct nursing to review the meal trays and tray tickets for accuracy or for resident safety in relation to food texture, food allergies and intolerances, or resident preferences before serving a meal. 1. An effective system was not in place to avoid residents known food allergies, and the facility failed to check one of six sampled residents' diet orders and meal trays for accuracy and safety before delivering the meal tray, (Resident 10). A review of Resident 10's medical record showed she was admitted to the facility on [DATE] with diagnoses that included a spinal cord injury, lupus, (a progressive disease that occurs when your body's immune system attacks your own tissues and organs that can affect all organs in the body) and diabetes. A review of the most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/10/22, indicated that Resident 10 was cognitively intact (able to think and reason) and required extensive assistance and was totally dependent on staff for all activities of daily living. During an interview on 2/14/23 at 11:19 am, Resident 10 stated, I have a lot of problems with the food and my allergies. I am allergic to any type of nuts, squash, honey, pineapple, and others. It has been a while since I had a reaction. When I first got here, I had an allergic reaction to pineapple. The Ceritified Nursing Assistant (CNA) came in and found out the food had pineapple in it. She got me help and Licensed Nurse, (LN) A and Registered Nurse, (RN) A stayed with me until after I was okay. They gave me Benadryl (antihistamine) through my port and an epi.(epinephrine injection-emergency treatment of severe allergic reactionsto food or other substance). I check my tray for all meals. A review of Resident 10's medical record Progress Note, dated 8/16/22 at 12:13 pm, showed worsening face edema (swelling); a second progress Note dated 8/16/22 at 2:12 pm indicated, Patient appears to have a rash on arms, legs, and back. Benadryl ordered which has been effective for patient's itch. Will continue to monitor. A review of Resident 10's Dietary Orders, dated 2/16/23, indicated the following food allergies: Coconut, nut-unspecified, paprika, pineapple, squash, and honey. During an interview on 2/14/23 at 3:18 pm, LN A stated. Yes, Resident 10 has had an allergic reaction to food. I was the one who helped her when she had an allergic reaction, we had to give her Benadryl intravenously, (IV) and an epi-pen. During a concurrent interview and record review on 2/15/23 at 7:38 am, the Assistant Director of Nursing (ADON) confirmed Resident 10 did have an allergic reaction to food. Benadryl was administered by RN A, not LN A via port-a-cath intravenously for an allergic reaction to food served, but LN A also stayed with Resident 10 until she was okay. During an interview on 2/15/23 at 10:02 am, Resident 10 stated, They get my allergies mixed up quite often, several times a week. I just don't eat it, they gave me Zucchini the day they had turkey and a cobbler, it was Sunday or Monday. Review of a document titled, Vibra Winter Menu, Week 3, dated Feb-12 through Feb-18 showed the meal residents were served at lunch on Monday 2/13 included turkey and zucchini. During an interview with the Dietary Manager (DM) on 2/14/23 at 11:15 am, he stated the facility's electronic medical record communicated with the diet office software to ensure the kitchen knew about resident's food allergies. A review of Resident 10's meal tray tickets dated 2/15/23 and 2/16/23, showed her diet as consistent carbohydrate, cardiac diet, mechanical soft/chopped, with thin liquids. It indicated allergies to all nuts, coconut, honey, paprika, pineapple, squash, and zucchini. In an additional interview on 2/15/23 at 10:05 am, the DM stated the Registered Dietitians (RD) surveyed the kitchen monthly, and observed resident trays for accuracy, including avoidance of food allergies. A review of lunch tray tickets dated 2/15/23 showed four (Residents 10, 14, 20, 136) out of 32 residents who received meals in the TCU (Transitional Care Unit) had allergies to foods such as eggs, peanuts, all nuts, coconut, honey, paprika, pineapple, squash, and zucchini. During observations on two nursing halls (Hall Rooms 120 - 130, and Hall Rooms 134 -146) on 02/16/23, Licensed Nurse B (LN B), LN C and LN D did not check breakfast meal trays or tray tickets for accuracy or resident safety regarding food allergies or textures. During an interview with LN D on 2/16/23 at 8:35 am, she stated No, I never checked the diet order with the trays before they pass them out. I did not know I was supposed to. No one ever told me, but I will from now on. During an interview with LN B on 2/16/23 at 9:04 am, she stated I do not check the trays before I pass them. I asked (about that) when I was hired .because other facilities do, but they said I do not need to check the diet orders. No, I do not remember who told me that. I check some (trays) when I help pass trays, but not regularly. No, I did not (check trays) this morning or yesterday, usually once a week. During an interview 2/16/23 at 9:10 am, LN C stated I will be honest, I do not check the trays before the staff passes out the trays. I do check once I go in the (resident) rooms while I am passing medications. Yes, they (residents) are already eating their trays by the time I get in the rooms. I know technically we are supposed to check all the diet orders for safety related to texture and allergies. During an interview at the nursing station on 2/16/23 at 9:15 am, LN A stated, I am going to tell you the truth, I am confirming all nurses should check all diet orders with the meal trays for all meals before the trays are passed out to the residents for safety. It is an order and it is recorded on the TARs. The texture, liquids, allergies, and all parts of the dietary order should be checked. During an interview on 2/16/23 at 3:50 pm, the ADON confirmed all diet orders and meal trays should be checked by the nurses before the trays are given to the residents. During an interview on 2/16/23 at 8:06 am, the Menu Planner (MP) stated her job included asking residents about their food allergies and making sure that information was included on meal tray tickets. MP explained her job was also to check resident meal trays for accuracy on tray line (meal assembly process), that Resident 10's zucchini allergy was listed on the tray ticket, and that she needed to check the tray tickets more carefully (to make sure food allergies were caught). During an interview with the RD on 2/16/23 at 3:03 pm he stated the kitchen QAPI (Quality Assurance Performance Improvement) projects currently in progress included tray studies and (food) allergies. He stated the allergies project had been going on for a while, and they did not just start during the survey. During an interview with the Administrator (ADMIN) on 2/17/23 at 9 am she stated the RDs did the kitchen audits. They also did test trays regarding resident meal appearance, temperature, and were also looking at food allergies. She further stated the RDs provided their results in monthly reports to the QAPI Committee. Review of a document titled, TCU QAPI 2023 Sign In Sheet, showed the TCU RD was present at the January and February meetings. Further review of the meeting agenda and minutes dated 1/25/2023 showed no evidence of food allergies as an existing QAPI focus. 2. Two residents (Residents 128, 134) reported their food preferences were not honored. Review of a policy titled, Serving a Meal, revised 1/2023, showed It is this policy of this facility to serve nutritionally substantive meals that are palatable and attractive in a safe environment that enhances the resident's quality of life. Review of a policy titled, Communication of Diet Orders & Diet Order Change, revised 2/2021 showed All cultural and religious dietary preferences will be acknowledged and provided within food production capabilities. No further policies regarding how the facility addressed resident food preferences were provided. During an interview on 2/14/23 at 11:15 am, Resident 128 stated she had written (on her meal ticket) she did not like fish but continued to receive fish twice. During an observation on 2/15/23 at 12 pm Resident 128's meal tray ticket showed a Regular diet with thin liquids, and dislikes apple juice. It did not indicate Resident 128 disliked fish. During an interview on 2/15/23 at 9:20 am, Resident 134 stated she was admitted on [DATE], and no one asked her about her food preferences. During an interview on 2/16/23 at 8:06 am, MP stated her job included interviewing patients, where she asked them about their food allergies, food likes, and food dislikes, and then transferred that information into the diet office software/meal tray tickets. MP stated she visited new residents usually within one to two days of admission unless they were sleeping. She shared she used a food preference form to interview residents, and it was easier to ask them what foods they disliked rather than going over the foods listed on the form. MP stated she most often asked residents about their food likes if the resident disliked a lot of foods. When asked about resident's reports that they sent notes to the kitchen regarding their preferences or alternate choices, MP stated she did not receive any written notes from residents. She stated if the notes were sent back on resident's meal trays, they likely ended up in the trash in the dish room. MP stated she was told any messages from nursing would be left on the answering machine. Her expectation was that nurses or residents would call her with any meal tray-related issues. During an interview with the RD on 2/16/23 at 3:03 pm, he stated he collected resident food preferences and sent the menu planner to see residents as needed. 3. Seven residents (Residents 18, 231, 229, 230, 21, 7, 14) reported a lack of choice or ability to access a selection of alternative meals. During an interview on 2/15/23 at 8:13 am, Resident 18 stated she didn't get food she liked, and no one came in regularly to check with her about her menu. She stated if she didn't like a meal, the staff offered alternatives, but there was nothing exciting on it - usually just sandwiches. She shared she loved foods like French fries, grilled cheese, Asian food, barbecue, and would like to receive them occasionally. She stated the Registered Dietitian had seen her twice since she'd been there, and That's when I got to start having salads sometimes. Review of Resident 18's Dietary (2) Orders, dated 8/17/22, showed Mechanical soft/ground meat, Consistency: thin. Comments: Texture is a preference - no swallowing issues per SLP (Speech and Language Professional). During an interview with Resident 231 on 2/14/23 at 10:19 am, he stated If I want to substitute, I have to call four hours before the meal comes out. He added that he had to call the main number for the facility, and then be transferred to the kitchen in order to leave a message regarding the substitution he wanted. During an interview with Resident 229 on 2/14/23 at 111 am, she stated she was never told she could have any substitutes for her food. She believed she had to eat whatever they brought her, even if she didn't care for it. The food was usually cold, tasteless. During an interview with Resident 230 on 2/14/23 at 3:32 pm, he stated the food was not good. I have never been offered substitutes, didn't even know I could. I just take what I get and Its usually cold. They told me that I am supposed to call the kitchen from the bedside phone. However, I do not have a bedside phone. During an interview on 2/15/23 at 10 am, CNA A and CNA B stated the residents were supposed to call the (menu planner) extension from their rooms by 10 am. If their tray came out and the resident didn't want the food, they could get them a substitute. Neither CNA could state what substitutes were exactly. They stated chef salad, grilled cheese, or fruit salad. They didn't know if the residents knew what the substitutes were. During an interview on 2/15/23 at 10:15 am, Resident 21 stated I was a cook at a hospital, the worst food (here) I have ever had .been here since 12/17/22, they do not offer alternates .my husband brings food. During an interview with Resident 7 on 2/15/23 at 2:23 pm, he stated he was supposed to call (the menu planner) via his room phone, however his room phone didn't work. If someone answered his call light on time, he could tell the aides, but they never got the message to the kitchen in time. During an interview with Resident 14 on 2/15/23 at 2:09 she stated, the food was Hospital Food, and it is what it is. If she wanted a substitute, she wrote it on her meal tray ticket. She was not aware of any phone number to call and didn't know what her choices were if she did want a substitute. They just gave her a cold sandwich. During an observation in the corridor near rooms 120 to 130 on 2/14/23 at 11:50 am, menus were posted in a glass display case on the wall about 5-feet above the ground. The dates on the four-week menu cycle did not match what was being served by the kitchen. The font on the menu was very small. The Thanksgiving 2022 holiday meal menu was still posted. Alternative menu choices were not posted for residents or families to review. In a concurrent interview, the Director of Quality and Risk Management (DORM) was asked If I were a resident in a wheelchair would I be able to read those? The DORM replied, That would be very difficult. She added the menu planner (staff) sent the weekly menus to residents every Saturday on their meal trays. Review of the weekly menu handout for Regular, Consistent Carbohydrate, Cardiac, Renal, and 2gram Sodium diets, dated 2/12/23 and provided by MP, all showed Lunch/Dinner Meal Alternatives as Deli sandwich (choice of turkey, roast beef, or ham); grilled chicken breast with vegetable of the day; chef salad; hamburger with vegetable of the day; grilled cheese sandwich with vegetable of the day; cottage cheese fruit plate. During an interview with Dietary Aide B (DA B) on 2/15/23 at 9:50 am, she stated the sandwiches made for residents were turkey, ham and roast beef. They didn't make egg salad or chicken salad for residents. They only made it for the café customers. DA B stated if a resident requested egg salad, they would make it, because it would also be used in the café, but they would not make a tuna sandwich if a resident requested it because they would have to open a huge #5 can of tuna to do it. During an interview on 2/15/23 at 10:05 am, the Dietary Manager (DM) stated they provided alternative menu choices for residents, and residents needed to call in their alternative choices or talk with the Menu Planner or RD. Nursing does not help with this. Nursing does help when there are problems. He further stated Every resident has a phone in their room, or the nurse can make a call if they can't. There are no problems with residents getting alternatives. If a resident requested a tuna sandwich, the staff would make it for her. When asked if residents were ever able to have food out of the cafeteria as an alternative, the DM stated that because of therapeutic diets, they had a strict policy that patients could not be fed out of the café, even if they are on a regular diet. During an observation on 2/15/23 at 12:25 pm, the phone number listed on the Menu Planner (the number provided to residents for alternative menu selections) was called and received this automated message: Menu planning, leave a message. During an interview with [NAME] B in the kitchen on 2/16/23 at 10:07 am, he stated there were generally three to seven resident alternate meal requests at lunch daily, and they had a set menu for alternate meals. During an interview on 2/16/23 at 8:06 am, MP was asked if residents got a choice of which alternative meals they would receive when they called for one. MP replied, They just have to call us, and we look at their diet (order). The resident doesn't get to choose. MP stated there were lots of issues with residents wanting to change their dinner meal, but it didn't get changed since her shift ended at 1:30 and nobody checked the message phone after that. She stated the Menu Planner picked up those messages when they came to work the next day. During an interview on 2/16/23 at 9:06 am, with the Chief Clinical Officer (CCO) and the Director of Quality and Risk Management (DORM) were asked about alternative menus, pointing out that many residents didn't have phones in their rooms, residents complained they were not getting their dinner meal requests, residents didn't get to select which alternative meals they wanted to receive, and nobody received the notes residents wrote on the tray tickets. The CCO stated the CNA, LN or Activities (a CNA) staff should look at the tray ticket as they deliver the tray and this should be in the meals serving policy.

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

Based on observation, interview and record review, the facility failed to ensure staff followed professional standards of practice for food safety and sanitation when: 1. Kitchen equipment was not clean. 2. Staff did not utilize proper hand hygiene and glove use to prevent cross food contamination. 3. Potentially hazardous foods were not cooled according to professional standards of practice for food safety. 4. Staff did not ensure that vegetables were properly prepared with food wash according to the manufacturer's recommendations. 5. Stored food was not labeled and dated, and one severely dented can was retained on the can rack with other cans intended for use. These failed practice had the potential of leading to foodborne illnesses for all residents eating food prepared at the facility. Findings: 1. During observations between 2/14/23 at 9:57 am and 2/17/23 at 12:00 pm, multiple pieces of equipment in the kitchen were not clean, including the blender, Robo Coupe (food processor), bulk food bins, can opener, ovens, and walls. During an observation on 2/14/23 at 11:02 am, two bulk food storage bins were greasy and black with grime. The bins contained brown rice dated 2/13/23, and parboiled rice dated 2/8/23. In a concurrent interview the Dietary Manager (DM), stated the dates indicated when new product was put into the bins and agreed the bins were not clean. He stated, It's grease and agreed it was not clean. On 2/14/23 at 11:08 am, an observation of the warming oven doors had a thick buildup of black and brown baked-on grease. The outside of the oven was soiled with splatters and food debris, and the top of the ovens had a thick layer of a gray substance resembling dust and food debris. During a concurrent interview with the DM, he stated that the ovens were there since 1987, were cleaned often and continuously, but were difficult to clean due to the accumulation of grease. During an observation on 2/14/23 at 11:08 am, the walls behind the warming oven showed a buildup of dark greasy residue and a thick gray substance resembling dust. The DM stated the walls behind the oven were cleaned weekly. During and observation on 2/14/23 at 4:25 pm, the can opener mount had a buildup of black grime where it was secured to the table. In a concurrent interview the DM, stated that he had never removed the can opener from the table to clean it. He agreed it was dirty, and he would contact plant ops to remove and clean it. During an interview on 2/15/23 at 3:05 with Director of Plant Services (DPS), he stated his team's responsibilities in the kitchen included the ice machine, lights, and fire suppression system every 6 months. He stated he had never been asked to clean the can opener until yesterday and in future would require either a work order or for dietary to do it themselves. Review of the facility provided policy titled, Employee Sanitation Practices, revised 4/19, indicated, can openers are washed after each use. 2. During an observation of tray line on 2/15/23 at 11:42 am, [NAME] A was preparing the lunch meal and opened the warming oven door that was not clean to obtain a container of rice. He closed the door, brought the container of rice to the warming table, and did not change his gloves or wash his hands before returning to the tray line. At 11:45 am, he opened the door to the dish warmer to obtain warm plates. He did not wash his hands or change to new gloves and touched food for cheeseburgers immediately after with contaminated gloves. At 11:49 am, he went to the warmer grabbed a grilled cheese and did not change his gloves before continuing with food preparation. On 2/15/22 at 11:47 am, during an observation of lunch tray line the therapeutic diet spreadsheets were brought to the kitchen to the meal planner (DA) C. She touched the diet spreadsheets with her gloved hands and continued with tray line, touching and placing resident food on trays handling plates and utensils. The meal planner did not wash her hands or change her gloves. On 2/15/23 at 11:47 am, during an observation with Dietary Aide (DA) B, was working the tray line, retrieved hot mugs of water from the warming oven, touched the unclean warming oven handle and door with her gloves and returned to the cold end of the tray line wearing the same gloves, handling the resident trays, eating utensils and ready to eat cold food. The DA B did not wash her hands or change gloves between tasks. Review of the facility provided policy titled, Employee Sanitation Practices, revised 4/19, showed Hand Hygiene, should be done .b) vii. After handling soiled equipment or utensils, c) viii During food preparation, as often as necessary to remove soil and contamination and prevent cross- contamination when changing tasks and d) x. before donning gloves to initiate a task that involves working with food. During an interview with the DM on 2/16/23 at 2:20 pm, he was asked when staff should change their gloves. He replied, Often. When staff are coming into the kitchen, they should restrain their hair, wash their hands, and put on gloves. They should change their gloves when changing tasks. 3. Potentially hazardous foods were not cooled according to professional standards of practice for food safety. (Cross Reference F801 and F802). Review of a policy titled, Employee Sanitation Practices, revised 4/19 showed D. Cooling process 1. The cooling process is monitored to assure appropriate cooling of all potentially hazardous foods to below 70 degrees Fahrenheit within 2 hours and from 70 degrees Fahrenheit to below 41 degrees Fahrenheit in an additional 4 hours (2 step process equals 6 hours). In addition, it showed 5.c) Perishable ingredients and foods are thoroughly chilled before preparation of mixed salads, especially egg, meat, poultry, fish and potato salads. Review of the 2022 FDA Food Code 3-501.14 showed (A) Cooked time/temperature control for safety food shall be cooled within 2 hours from 135°F to 70°F, and within a total of 6 hours from 135°F to 41°F or less. And (B) Time/temperature control for safety food shall be cooled within 4 hours to 41°F or less if prepared from ingredients at ambient (room) temperature, such as reconstituted foods and canned tuna. During an interview with DM on 2/14/23 at 10:05 am, he stated the refrigerated food needs to be used within 3 days or put in the freezer. The DM was informed that he was not using the correct cooling process. The correct process according to the FDA food code 3- 501.14, prevents microorganisms from causing foodborne illness. The food code provides for cooling from 135 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours and 70 degrees Fahrenheit to 41 degrees Fahrenheit in 4 hours. A record review of the Employee Sanitation Practices, revised 04/19, indicated, the cooling process is monitored to assure appropriate cooling of all potentially hazardous foods to below 70 degrees Fahrenheit (°F ) within 2 hours and from 70°F to below 41°F in an additional 4 hours (2 step process equals 6 hours. During an observation in the kitchen walk-in refrigerator on 2/14/23 at 10:38 am, a pan of cooked pork roast dated 2/12/23, was covered and on the shelf, with temperature 36.4 °F. In addition, a pan of cooked rotini pasta dated 2/13/23, was covered and on the shelf, with temperature 39 °F. During a concurrent observation and interview on 12/15/23 at 9:50 am, [NAME] B stated he rarely did food cooling. He stated food temperatures are checked every hour until the food item reaches 40 °F. Once the food item was 40 degrees, the food is refrigerated. I must cool down food within 4 hours. A concurrent review of the posted Food Cooling Temperature Log, dated February 2023, directed staff to cool food from 140°F to 41°F within four hours. It showed on 2/11/23 staff began cooling logs for both carrots and pork at 6 pm. There was no starting temperature documented to confirm the food was cooled from 140°F to 41°F in the time allowed. The first temperature logged for the carrots was 75°F after one hour and then 34°F after 2 hours. The first temperature logged for the pork was 80°F after one hour, and 35°F after two hours. [NAME] B stated they should have a starting temperature. Further review of the log showed there was no cooling log for the cooked rotini pasta dated 2/13/23 previously observed in the walk-in refrigerator. During an interview with the DM on 2/15/23 at 10:05 am, he stated hot food should have a start temperature and time, and then be temped every hour, up to 4-hours. The cooling log should be started anywhere from more than 140 °F to 160 °F, and if it does not reach 40°F within 4-hours the food must be tossed. During an interview with DA D on 2/15/23 at 10:05 am she stated she made the egg salad and tuna salad and described this process: She chopped up hard boiled eggs (as purchased), added mayonnaise, mustard, salt, pepper, and fresh onion, and took 10 to 15 minutes to make. DA D stated if she was making tuna salad, the tuna would be at room temperature because it would come from the shelf in dry storage. When asked if she ever took the temperature of her egg salad or tuna salad she replied she only checked the temperatures for egg salad used in the café. For residents, she checked the temperature before making their sandwiches, and it was usually 30 to 31°F. She stated she didn't write the temperatures down anywhere. Egg salad is not part of our meals (standard, resident menus) anymore. 4. Review of a policy titled, Employee Sanitation Practices revised 04/19, showed To prevent chemical food poisoning: all fresh fruits and vegetables are wash thoroughly before preparation and/or service. During an observation on 2/14/23 at 10:40 am, vegetables were being washed in a sink utilizing Fit Antibacterial Fruit and Vegetable Wash automatically dispensed from a gallon jug mounted above the prep sink. In a concurrent interview with DA at the pantry prep sink, she stated the vegetable wash product was used to clean the produce. The produce was put into a plastic container with the fruit and vegetable wash, and then rinsed with clean water. She stated she was not sure if there was any length of time the product should be in the wash product. The wash product concentration was not checked. she stated she was unaware what the PPM (part per million concentration) for the vegetable wash should be and had not received any training about using test strips. During an interview on 2/14/23 at 10:49 am, DM stated he was not sure how long the veggie wash was premixed, in the container he had not checked it. The DM stated that test strips were utilized daily by the DM, the morning pantry person, the menu planner or the cook. The task was not specifically assigned, and the testing was not logged. In a concurrent interview with DA B, she stated she started work at 5 am and was unaware and had not received any training about using the test strips or testing the vegetable wash concentration. During further interview, the DM stated he was unaware of where they kept the vegetable test stripes, they were not by the veggie wash. The DM was unable to find the test strips near the vegetable wash or in his office desk drawer. He stated, they were not where they are supposed to be. A review of the manufacturer's instructions for Fit Antibacterial Produce Wash, showed Use a dedicated preparation/cleaning area for produce. Wash hands before preparing produce. Use Fit for ALL fresh produce. Produce Washing Procedure: Clean and sanitize sink, Place produce in sink and dispense Fit solution, Submerge produce in Fit solution, Soak for at least 30 seconds, Drain and store produce. Testing for pH levels: To test the solution, simply tear off a small strip of pH paper, dip into the test solution, then instantly compare the resulting color with the .pH color chart. Solution is acceptable to use at pH 3.5 or lower. If test strips show a pH above 3.5 or show any green, discard solution and refill. 5. During an observation in the walk-in refrigerator on 2/14/23 at 10:38 am, a plastic container held hard-cooked eggs. There was no label or date on the container. In a concurrent interview the DM confirmed there was no label or date and discarded the eggs. During an interview with the DM on 2/16/23 at 2:20 pm, he stated labeling and dating should include the contents (what it was), and date it was placed in that container. He further stated a lot of staff didn't take the time to put the use-by date on the label, but they used their food storage guidelines to figure it out. They threw away food not labeled and dated. Staff should count the use-by date from the oldest ingredient dates. Review of a policy titled, Employee Sanitation Practices, revised 4/19, showed C.2. Keep all foods covered .Label and indicate date of transfer. Review of the 2022 FDA Food Code 3-501.17 showed Refrigerated, ready-to-eat, time/temperature control for food safety food .shall be clearly marked to indicate the date or day by which the food shall be consumed .sold, or discarded when held at a temperature of 41° or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 2/14/23 at 10:30 am, during an observation in the dry storage room a can of sliced strawberry topping had a large dent in it. During a concurrent interview with the DM in the dry storage room he stated, whoever receives and unpacks the delivery looks for dented cans and throws them away. The DM stated the can was delivered around Christmas time and had not been thrown away. A review of the 2022 FDA Food Code §3 -202.15 stated damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food and contaminants such as Clostridium botulinum may cause Botulism toxin to be formed.

Based on observation, interview and record review, the facility failed to facilitate and safely store food from outside sources for residents when: 1. Residents were not allowed to store perishable food, and there was not an effective system in place to educate residents and family regarding food brought in from the outside. They were unaware perishable food could be safely stored in a refrigerator. 2. There was not an effective system in place to consistently educate and train nursing staff regarding storage, provision, and reheating of food brought in for residents. These failures had the potential to result in foodborne illness, decreased food intakes, weight loss, decreased medical status and quality of life for all residents living in the facility. Findings: 1. During an observation on 2/15/23 at 11:49 am, Resident 129 was gone to dialysis but had snacks at her bedside. During an observation on 2/16/23 at 8:15 am, Resident 129 refused breakfast. A concurrent review of her breakfast tray ticket showed she was on a Renal, Consistent Carbohydrate diet with regular texture. In a concurrent interview Resident 129 stated her snacks were brought in by her family/housekeeper two days prior on 2/14/23. Further observation of her snacks showed a jar of almost empty cheese sauce with Refrigerate after opening on its label, baggies of corn chips, crackers, cheddar cheese, and a product Resident 129 identified as homemade liver pate. None of the snack food items were dated, and the perishable items had not been refrigerated since their arrival 2 days prior. Resident 129 stated no one told her there was a refrigerator to put her food into. In a concurrent observation Certified Nursing Assistant (CNA) D entered the room and began writing the date 2/14 on the baggies of snacks but did not remove the unrefrigerated perishable foods. He stated he was taught residents could bring in food from home if it was verified by the Dietary Department that it followed the diet order. Resident 129 stated she was told she could eat what she wanted since she didn't always eat what she received from the facility. CNA D stated he needed to go clarify should be done. During an interview with Licensed Nurse (LN) B and Certified Nursing Assistant (CNA) D on 2/16/23 at 8:45 am, LN B stated she and Resident 129 talked about how her snacks should be in the refrigerator. LN B stated she was not there every day, but the higher ups told staff they couldn't use ice chests in resident rooms since a resident had ants in their room. LN B and CNA D stated they did not observe Resident 129's snacks the previous or current day, but they had seen snacks at her bedside in the past. During an interview with the Chief Clinical Officer (CCO) on 2/15/23 8:35 am, she stated there was one resident food refrigerator in the facility, located in the Day Room near the nursing station. The CCO showed one cupboard in the Day Room contained many shelf stable food items for one resident because historically, when the items were stored in her room, there was a problem with packages spilling and attracting insects. During further observation, a sign on the refrigerator door showed No Outside Food. The CCO stated Oh, that was from when we were in COVID. Observation of the interior of the refrigerator showed contents were all from the dietary department, except the door contained three unopened beverages (One soda and two soymilk beverages) labeled for two residents. During an interview on 2/15/23 at 9:37 am, CNA C stated if a resident ordered food delivered by delivery service, the food usually came to the front desk. The unit clerk received it, and nursing took it to the resident. We can't store patient food anywhere. We don't allow patient food in our refrigerator. During a confidential interview on 2/15/23 at 11 AM, one of four residents stated that alternate foods requested from the facility weren't received, so family had to bring food in every meal. Now I know I can use the refrigerator. During an interview with Resident 130's daughter on 2/16/23 at 3:30 pm, she stated she was never told she could not bring food from home to resident, but she was recently advised that if she took the food she brought into his room, they would have to throw away if kept at bedside for more than 4 hours. Review of Resident 18's Dietary (2) Orders, dated 8/17/22 showed she had a nocturnal (at night) tube feeding, and a regular diet/mechanical soft/ground meat/thin liquids diet. Comments: Texture is a preference - no swallowing issues per SLP (Speech and Language Pathologist). A review of Resident 18's Adult Nutrition Assessment's performed by the RD and dated 7/21/22 through 1/26/23 showed Resident 18 with severe malnutrition, and a goal for gradual weight gain. During an observation on 2/15/23 at 8:13 am, Resident 18 sat in her bed with a partially consumed breakfast tray on the bedside table. When asked about her largely untouched breakfast she stated, I felt hungry, but my eyes were bigger than my stomach. She stated the food was ok, but she didn't get foods she liked. Resident 18 shared she had called out and ordered food to be delivered - Asian-style food once, and a burger and fries another time, but it's awfully expensive. She stated she could only eat a little bit at a time, so most of the food she ordered got thrown away, making the cost not worth it. Resident 18 stated nursing had never offered to put any food away for her to eat later, and she didn't know she could ask them to do that. She stated she asked staff about getting food heated, but It's frowned on, staff are worried about getting in trouble (if they do that). The staff never educated her about bringing food in from the outside. She didn't know she could have food brought in and stored in the refrigerator. 2. During an interview with CNA D on 2/15/23 at 8:32 am he stated he wasn't sure if residents could have food from the outside. He wasn't sure what happened, or was supposed to happen with the food when it came in. He stated nursing never reheated food for residents, but if a resident complained of cold food, nursing called for a new tray from the kitchen. During an interview with the Infection Prevention Nurse on 2/15/23 at 9:27 am, she was asked about food from the outside for residents. She stated nursing put resident food in the resident refrigerator. Staff labeled it with a patient sticker, the date, and with expiration in a couple of days. Then she clarified I would say 2 to 3 days. She stated they would serve one portion at a time to the resident. When food was taken into the resident's room, any uneaten portion would be discarded. Since COVID has come we haven't done much to reheat food. People mostly bring drinks in. She stated if a meal tray was cold, they could not reheat it. If the resident didn't want their meal, nursing either called the kitchen for new food, or offered residents food from the pantry. When asked how long a resident could have food on their bedside table she replied, If food has been sitting out for more than two hours it should be disposed of. When asked if a resident had their own (personal) perishable food, how long could it sit out, she replied, It should not be sitting out for more than 6 hours. During an interview with the CCO and the Director of Quality and Risk Management (DORM) on 2/16/23 at 9:06 am, regarding resident food brought in from the outside, the CCO stated if food was in a single serving container it could be put in the refrigerator. If it was in a larger, multi-serving container, staff would put it in the refrigerator for up to 3 days. She stated education to residents and family regarding food from the outside was provided to them as needed. She explained the Registered Dietitian (RD) was responsible to educate residents and families about this, however, if families stopped by the front desk to ask about bringing in food, or if nursing staff observed family bringing in food, they would educate them. The CCO stated during COVID they encouraged families to not bring food in, but now that things have loosened up, they allow food to be brought in. When asked what happened if residents and their families didn't ask about bringing food in, the CCO replied That's a really good question. We have (resident) care conferences. She stated doctor's diet orders should be followed. When asked what if the resident used a delivery service such as Door Dash, the CCO replied if the food was not compliant with the diet order, the resident signed a Dietary Waiver. The RD was responsible to provide education and the waiver, but nursing could also provide it. The RD was informed about residents in need of a Dietary Waiver through the Communication Board in the medical record and would have to follow up the next day for resident education. The CCO added these situations were also brought up with staff in the daily Stand Up meeting. The CCO stated if food was perishable, the residents could eat it, but she didn't know how long food could stay safe out of the refrigerator. It's a big question. When asked about a surveyor's observations of unrefrigerated perishable snacks at Resident 129's bedside for multiple days and nursing staff finally dating that food but not removing the unsafe products, the CNO stated she would have the unrefrigerated perishable foods removed. During further interview the CCO on 2/16/23 at 9:06 am, she stated training for nursing staff regarding food from home was as needed. If CNA's had questions they asked the nurses. She confirmed charge nurses were the gate keepers and CNA s and nurses needed to be educated. She did not think the food from home topic was included in education for Licensed Nurses or CNAs. The CCO stated there was currently no education regarding food from home provided in the admission package for residents and families. She shared there was a new letter for admit packets, created by the CEO, titled, Hello and Welcome to Vibra, but it had not been implemented yet. During an interview with the Registered Dietician (RD) on 2/16/23 at 10:30 am, he stated staff should know when any perishables are brought in, and they can store it in the refrigerator in the Day Room. He stated the food should be in a sealable container and labeled with the resident's and the date stored. The RD explained the maximum time perishable foods such as meat and cheese should be at resident's bedside was 4 hours, and then it should be thrown away. During an additional interview with the RD on 2/16/23 at 3:03 pm regarding food from outside sources he stated the nursing staff were who were the most present and aware to realize if a resident received food from outside sources. He stated nursing did the resident education regarding food from the outside, but they called him to provide additional education as needed. Review of a policy titled, Food From Outside Sources, revised 1/22, showed To support patients nutrient intake, foods from outside sources may be provided patients with appropriate storage and handling .Foods from outside will be stored in designated unit refrigerator, labeled with the patient's name, date and time and discarded after 3 days. Potentially hazardous foods may not be stored in patient rooms and should be eaten upon receipt. Review of an undated letter titled, Patient Foods Brought From Outside Facility, was signed by the Dietary Manager, and was attached to the Food from Outside Sources policy. It showed There are refrigerators located on all units for holding cold food items from outside the facility. The food must be in a sealed container and labeled and dated with the patient's full name, room number, and the date the item was brought into the facility. The food item will only be kept for 3 days before being discarded .Hot items brought into the facility should be consumed within one hour to ensure food safety and can not be kept and reheated.