Feather River Care Center

Inspectors wroteBased on observation and interview, the facility failed to protect two of two sampled Residents (Resident 1 and Resident 2) while performing wound care when the cleaning and sanitizing of the surgical scissors was not done between each use. This failure had the potential to cause widespread infection among the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure protection from sexual abuse (non-consensual sexual contact of any type with a resident) for one of three sampled residents (Resident 1) when Resident 2 touched Resident 1's side of the body on 12/20/25, and touched Resident 1's chest area on 12/22/25These failures led to the compromised safety of Resident 1 and had the potential to affect Resident 1's emotional and psychosocial well-being as well as putting other residents at risk.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse (non-consensual sexual contact of any type with a resident) for one of 3 sample residents (Resident 1), when a staff member witnessed Resident 2 touch Resident 1's side of body on 12/20/25. This failure led to the compromised resident safety and contributed to a subsequent incident on 12/22/25, when Resident 2 was witnessed with a hand on Resident 1's chest area. During a record review of facility's policy titled Abuse, Neglect, and Exploitation dated 2025, indicated Abuse means the willful infliction of injury.intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include.certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that four out of four sampled residents (Residents 1, 2, 3, and 4) had an individualized smoking safety care plan that identified smoking-related risks, resident-specific interventions, and safety measures. Despite the facility's knowledge that these residents smoked, there was no documented care-planning process to address smoking supervision, designated smoking location, safety precautions, or ongoing evaluation and revision of the plan of care. This failure resulted in residents not receiving individualized, person-centered care related to smoking safety, with smoking-related risks remaining unrecognized and unmet, and had the potential to place residents at risk for decline in health status, including injury or other adverse outcomes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and enforce its smoking policy when four of four residents were identified as smokers and the facility did not establish a designated smoking area as required by facility policy. This had the potential to place residents who smoke at increased risk for injury due to smoking in undesignated areas. During a review of the facility's Resident Smoking Policy, dated 12/01/25, the policy indicated that residents deemed safe to smoke, with or without supervision, are permitted to smoke only in designated smoking areas, at designated times, and in accordance with the resident's individualized care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of six sampled residents (Resident 1) remained free from restraint when a staff member restrained Resident 1 upright in a wheelchair. This placed Resident 1 at increased risk for injury, accident, and negative health outcomes.

Inspectors wroteBased on interview and record review, this requirement was not met when the facility failed to ensure a Licensed Vocational Nurse's (LVN 1's) license was current. This resulted in a potential lapse in administrative oversight of requirements for licensure, and the potential for medical error or harm. A review of the facility's policy titled License Verification dated 2025 indicated, All personnel that require a license or certification shall be verified through the appropriate issuing agency, and, 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. The policy further stated, Any licensed/certified employee is responsible for maintaining continuing education hours as required for current licensure/certification status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update the care plan for three of three residents when:Resident 1's care plan was not updated with a 24 hour 1:1 monitor (where one staff member is assigned to continuously monitor a single resident for behaviors, needs, etc.) and visual checks every 15 minutes at night. Resident 2's care plan did not state an intervention of a 1:1 monitor. Resident 3's care plan did not state an intervention of a 1:1 monitor. This failure had the potential to result in physical and/or psychosocial harm to other residents and staff. During a record review of facility policy titled Care Plan Revisions Upon Status Change dated August 2024, indicated the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 2) was protected from physical abuse when Resident 3 hit Resident 2 with a closed fist which resulted in a bruised right eye. This failure caused Resident 2 to feel anger and discomfort, and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility's nursing staff failed to recognize and report a change in condition for one of eight sampled residents (Resident 7). This failure caused Resident 7 to have a delay in acute care treatment required, and the need for new placement after a hospitalization related to the lack of communication when Resident 7 had a change in condition. A review of the facility's policy revised 8/2024, titled, Notification of Changes, indicated the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. [...]

Inspectors wroteBased on observation, interview, and record review, this facility failed to accommodate the need to communicate with of one (Resident 1) of four sampled residents when the facility failed to provide any means of translation to a Hmong only speaking resident. This failure resulted in Resident 1 not being properly assessed and Resident 1's pain was not treated.

Inspectors wroteBased on observation, interview, and record review, this facility failed to address and treat the pain of one (Resident 1) of four sampled residents when Resident 1 had an accident in the shower chair, sustained an injury, and complained of pain. This resulted in a complete omission of pain treatment and management and Resident 1 suffering without any pain relief.

Inspectors wroteBased on observation, interview, and record review, this facility failed to ensure licensed staff the competencies and skill set necessary to provide nursing care for one (Resident 1) of four sampled residents when: Nursing staff did not assess and document when Resident 1 had an accident and sustained an injury. Nursing staff did not complete a change in condition or alert the physician. There was no care plans completed to address the accident and injury Resident 1 had. This resulted in Resident 1 not receiving the treatment and pain relief needed for Resident 1's injury.

Inspectors wroteBased on interview and record review the facility failed to protect one of two sampled residents (Resident 2) from abuse when Resident 2 was pushed out of her wheelchair to the floor by Resident 1. This failure had the potential to cause physical and psychosocial harm to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR, evaluation for serious mental illness and intellectual disability,) for one of two sampled residents (Resident 1) during an admission from another Skilled Nursing Facility. This failure had the potential for Resident 1 not to receive a plan of care to meet his behavioral and mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had a comprehensive care plan that was person-centered to meet his mental health needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 1 had a behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs. This failure resulted in a resident-to-resident altercation and a transfer to the hospital for suicidal ideation.

Inspectors wroteBased on interview and record review, the facility failed to inform the conservator (an individual appointed by a court to oversee the mental health care of an individual with a serious mental illness who is unable to make decisions themselves) of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers in advance of a medication change for one of two sampled residents (Resident 1). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update the care plan with a 1:1 monitor (where one staff member is assigned to continuously monitor a single resident for behaviors, needs, etc) for one of four residents (Resident 1) when Resident 1 walked past Resident 2 and hit him in the back of his head. This failure had the potential to result in physical and/or psychosocial harm to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1a. Certified Nurse Assistant (CNA) I wore the same isolation gown (worn over clothing and used to prevent the spread of infection) while providing care to Resident 24 (who was diagnosed with Clostridium difficile, C-diff, a bacterium that caused diarrhea, was spread from person to person by direct contact, could cause serious illness, hospitalization, or even death) and Resident 23 (who was not diagnosed with C-diff); and 1b. There was no dedicated cleaning equipment for Resident 24's bathroom; and 2. The nurse's station counter was chipped and not able to be disinfected. These failures had the potential to spread infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to privacy were protected for five out of 13 residents sampled for patient rights, (Resident 33, Resident 18, Resident 22, Resident 8, and Resident 5), when Resident 20 entered their room uninvited. This had the potential to make Resident 33, Resident 18, Resident 22, Resident 8, and Resident 5 feel unsafe in their room, and their privacy to be disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and treatment to one out of 13 sampled residents (Resident 201) when Licensed Nursing (LN) did not accurately assess the condition of Resident 201's feet, create a care plan (written plan that described needed care and how care would be provided), and the physician was not notified of the condition of Resident 201's feet. This failure had the potential to negatively impact resident health status and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of one newly admitted sampled resident (Resident 201) was provided with medical related social services when a referral for a follow up appointment with vascular surgeon (a surgeon that specialized in diseases of the veins and arteries also known as blood vessels) was not done. This had the potential for a decline in health status for a resident that recently suffered a stroke (occurred when something blocked the blood vessel that supplied blood to the brain).

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a clean and orderly environment in the dietary department when there was an unlabeled storage bin and four storage bins with visible dust and adhesive tape residue accumulated on the lids. These failures had the potential to lead to the spread of infections, communicable diseases, and food borne illness to all residents who are served out of this kitchen.

Inspectors wroteBased on observation and interview the facility failed to ensure that all their bedrooms accommodated no more than four residents. This had the potential to result in residents not reaching and maintaining their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 13 sampled residents (Resident 4) had access to the resident call system when the call light was not within reach. This failure had the potential to cause a delay in care and could endanger Resident 4's health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with dignity and respect during communication with an employee when asking about lost clothing. This failure caused Resident 3 to feel angry, and had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) needs were accommodated when a second bedside table was removed from her room that stored art supplies used daily. This failure resulted in Resident 3 becoming frustrated, angry, and violated the right to accommodate specific resident needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a care plan for one of three sampled residents (Resident 3) was revised and updated to reflect current individual needs for pain management. This failure resulted in the resident ' s individual care needs to go unrecognized, and the potential for a further decline in resident ' s physical, mental, and psychological status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete daily hair care for one of three sampled residents, (Resident 3). This failure had the potential to result in Resident 3 feeling depressed with poor self-esteem, frustrated, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident rights for 6 out of 6 residents (Resident 1, 2, 3, 4, 5and 6) when nursing staff failed to safeguard the resident ' s dignity and respect when they ignored call lights, calls for assistance, and failed to administer pain medications in a timely manner for Resident 2. These failures resulted in residents feeling angry, sad, scared, and with an increase in anxiety and pain. Findings A review of a policy and procedure titled, Resident Rights, copyrighted in 2024, states that a resident has the right to a dignified existence and self-determination. The resident has a right to be treated with respect and dignity, and a right to a safe, comfortable homelike environment, including support for daily living. [...]

Inspectors wroteBased on interview, record review and observation, the facility did not meet this requirement when three of eight sampled residents (Residents 1, 4, and 5) stated their soiled briefs were not changed in a timely manner, including one resident (Resident 1) being left wet for approximately 12 hours until the next day's shift reported for duty. This had the potential to result in negative health outcomes (infection, illness), skin breakdown, and residents' loss of dignity.

Inspectors wroteBased on interview, observation, and record review, the facility failed to meet this regulation when two of eight sampled residents (Residents 1 and 2) reported to the facility that Licensed Vocational Nurse (LVN A) spoke to them in a disrespectful manner; that LVN A threatened to withhold medication from Resident Two; residents indicated they were fearful of him. This had the potential to result in psychosocial (mental) harm, pain, and adverse medical outcomes.

Inspectors wroteBased on interview, observation, and record review, this requirement was not met when a staff member closed the room door for one of eight sampled residents (Resident 3), and silenced the resident's call light. This resulted in the potential for psychological harm and adverse outcomes and was contrary to the facility's stated policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and respect while eating meals. This deficient practice had the potential to negatively affect Resident 2's psychosocial well-being and did cause Resident 2 to become frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders for wound care were obtained upon admission to the facility for one of three residents, (Resident 2) sampled for new admission. This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 2 did have specific needs that were not identified in a timely manner.

Inspectors wroteBased on interview, record review, and the facility ' s policy, the facility failed to develop a baseline care plan within 48 hours for one of three residents (Resident 2). This failure had the potential to not meet the individual needs of the resident and cause a negative clinical outcome.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the temperatures were at comfortable levels for six of 21 sampled Resident Rooms (room [ROOM NUMBER],5, 6, 7, 8, and 9). These failures resulted in Resident 1 to be uncomfortable, feeling hot and sweaty.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure room temperatures were at a comfortable level for six of 21 resident rooms sampled. This failure had the potential for 11 of 44 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) to be susceptibility to loss of body heat, risk of hyperthermia and the actual feelings of being hot, sweaty, having difficulty breathing and not wanting to stay in their room. Findings A review of the facility's, undated, policy titled Resident Rights revealed, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. A review of the facility's, undated, policy titled Safe and Homelike Environment revealed, 7. The facility will maintain comfortable and safe temperature levels. a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to personal privacy for one of one resident (Resident 1), when medical treatment was provided to Resident 1 without privacy being provided by staff. This failure had the potential to cause distress for Resident 1 and threaten her health and well-being.

Inspectors wroteBased on observation and interview the facility failed to ensure the communication call light system was working for two of three residents (Resident 1 and 2), sampled for working call lights, when Resident 1 and Resident 2's call light would not stay on after the button was depressed. This failure had the potential for Resident 1 and 2 to be at risk for accidents and their care needs not to be met. Findings A review of the facility's, undated, policy titled Call lights: Accessibility and timely Response indicated The purpose for this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident assessments accurately reflected the resident's current status for one of five sampled residents (Resident 1) when his admission Minimum Data Set (MDS, a standardized resident assessment) dated 3/3/2024, inaccurately assessed that Resident 1 was admitted with an indwelling catheter (a catheter that is maintained within the bladder for the purpose of continuous drainage of urine into a drainage bag). This failure had the potential for the resident to not receive treatments and care that met their individual needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop individualized and comprehensive care plans that identified the needs for one of five sampled residents who was exhibiting a behavior issue by constantly removing all his clothes (Resident 1). These failures had the potential for Resident 1 not to receive the necessary care and services to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate care and services were provided to one of five sampled residents (Resident 1) who was exhibiting the sign and symptoms of urinary tract infection (UTI, bacteria in urinary system) when Urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine)) was not done in a timely manner as ordered. This failure had the potential for delaying Resident 1 ' s treatment and to develop urosepsis (systemic body infection) and other related clinical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the laundry practices were implemented, and handled and processed in a safe and sanitary manner when numerous bags of soiled laundry were observed to be overflowing the laundry room and stored inside a broken dryer. This failure had the potential to spread disease and infection throughout the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a system was implemented to alert staff when residents exited the building onto the outside resident patio area. This affected 1 (Resident #26) of 3 sampled residents reviewed for accident hazards. On 09/20/2023 at approximately 3:00 AM, Resident #26 exited the facility without staff's knowledge and sustained a fall. It was determined the provider's non-compliance with one or more requirements of participation had caused or was likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25(d) Accidents, at a scope and severity of J. The IJ began on 09/20/2023 at approximately 3:00 AM when Resident #26 exited the facility without staff's knowledge and sustained a fall. [...]

Inspectors wroteBased on record reviews, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 3 (Residents #8, #6, and #19) of 5 residents reviewed for resident assessments.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 (Resident #1) of 1 sampled resident reviewed for Preadmission Screening and Resident Review (PASRR) requirements, 2 (Resident #8 and Resident #11) of 2 sampled residents reviewed for pressure ulcers, and 1 (Resident #40) of 1 sampled resident reviewed for hospitalization.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide care and services to prevent potential worsening of pressure ulcers for 2 (Resident #8 and Resident #11) of 2 sampled residents reviewed for pressure ulcers. Specifically, the facility failed to consistently implement and provide wound treatments as ordered by the Wound Specialist and failed to follow the Wound Specialist's recommendations for Resident #8 and Resident #11.

Inspectors wroteBased on observations, record reviews, interviews, and facility document and policy review, the facility failed to ensure 2 (Licensed Vocational Nurse (LVN) #2 and LVN #3) of 2 LVNs observed administering insulin pens were trained on the proper use of insulin pens and their skillsets were evaluated to ensure they could competently administer insulin pens in accordance with the manufacturer's guidelines. This failure affected 2 (Resident #32 and Resident #8) of 2 residents observed receiving insulin by way of an insulin pen injection and had the potential to affect all 10 of 10 residents with orders for insulin pens.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to follow physician orders to obtain laboratory testing for 3 (Residents #8, #13, and #23) of 3 residents reviewed for laboratory services.

Inspectors wroteBased on interviews, record review, and facility document and policy review, the facility failed to ensure 2 (Resident #144 and Resident #143) of 2 sampled residents reviewed for dignity were treated with dignity and respect. Specifically, staff searched Resident #144's personal belongings without consent, and a staff member responded to Resident #143 by using profanity during a conversation with the resident.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse for 1 (Resident #144) of 2 sampled residents reviewed for abuse allegations.

Inspectors wroteBased on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete quarterly Minimum Data Set (MDS) assessments in a timely manner for 2 (Resident #3 and Resident #13) of 5 residents reviewed for resident assessments.

Inspectors wroteBased on record review and interview, the facility failed to follow-up on Level II Preadmission Screening and Resident Review (PASRR) recommendations for 1 (Resident #1) of 1 sampled resident reviewed for PASRR requirements.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the use of bed rails was reflected on the comprehensive care plan for 1 (Resident #29) of 2 sampled residents reviewed for the use of bed rails.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure staff followed physician orders for 1 (Resident #23) of 5 residents reviewed for medication use.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete pre- and post-dialysis assessments before and after each dialysis appointment for 1 (Resident #26) of 1 sampled resident reviewed for dialysis care.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure bed rail assessments reflecting the need for bed rails were conducted and informed consents were obtained prior to the use of bed rails for 2 (Resident #29 and Resident #11) of 2 sampled residents reviewed for the use of bed rails.

Inspectors wroteBased on observations, record reviews, interviews, facility policy review, and review of manufacturer's guidelines, the facility failed to ensure a medication error rate of less than 5 percent (%). The facility had 3 medication errors out of 28 opportunities, resulting in a medication error rate of 10.71 %, affecting 3 (Residents #32, #8, and #22) of 10 residents observed during medication administration. Specifically, licensed nursing staff did not prime an insulin pen (safety test) in accordance with the manufacturer's guidelines prior to administering insulin to Resident #32 and Resident #8, and staff administered the wrong inhaler and dosage to Resident #22. In addition, when staff administered two puffs of the wrong inhaler to Resident #22, the nurse did not wait one minute between puffs as directed by the manufacturer's guidelines.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure nursing staff documented the administration of medication for 1 (Resident #5) of 5 residents sampled for medication review and failed to document the completion of wound care for 1 (Resident #8) of 2 residents reviewed for wound management.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that 1 (Resident #1) of 5 residents reviewed for vaccination status was offered the influenza vaccine.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #23) of 5 residents reviewed for vaccination status was offered the Coronavirus-2019 (COVID-19) vaccine.

Inspectors wroteBased on interview and record review, the facility failed to meet this requirement when quarterly care conferences were not held for one of three sampled residents (Resident 1). This resulted in the facility's failure to ensure that the comprehensive care plan was ireviewed and revised by an interdisciplinary team who had knowledge of the resident's needs, and that each resident and resident representative was involved in developing the care plan and making decisions about his or her care.

Inspectors wroteBased on interview and record review, the facility: 1. Failed to designate a Director of Nursing (DON) after DON left the faciity on 9/27/2023. 2. Failed to staff a Registered Nurse (RN) for a minimum of 8 hours on the following days: September 2, 3, 4, 28, 29, 30 and October 4, 5, 6, 10, 11, 15, 22, 23, 24, and 28 of 2023. These failures resulted in decreased supervision of nursing staff to ensure the delivery of quality of care of all residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy to ensure the health and safety of Resident 1 when facility staff did not identify, report, protect and investigate allegations of abuse. This resulted in Resident 1 having pain, emotional distress and had the potential to put all residents at risk for abuse. Refer to F 697.

Inspectors wroteBased on interview and record review, the facility failed to ensure a non-verbal resident (Resident 1) had a plan of care for pain that met her needs when her pain was not monitored, reassessed, and physician was not notified of changes. This failure resulted in Resident 1 experiencing increased pain levels and had the potential to negatively affect the resident's physical and psychosocial (emotional and social) well-being and decrease mobility, function, and quality of life. Refer to F607.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was stored, prepared and distributed in accordance with professional food safety standards when: 1. The kitchen was not sanitary. 2. Staff were not wearing aprons. 3. Fixed equipment (equipment that cannot be cleaned in the dish washer or in the three-compartment sink) was not washed and rinsed prior to sanitizing. 4. Food was not stored, labeled, dated or discarded appropriately. 5. Nutrition supplements stored on medication carts and distributed by nursing during medication administration were not monitored for safe temperatures, stored or discarded within food safety guidelines. 6. The ice machine was not sanitary. 7. An air gap was not present in the cook's food preparation sink. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a system was in place to help residents, their families and other visitors understand safe food handling practices for food brought in from outside sources. This failure has the potential to increase the risk of foodborne illness for residents receiving food brought in by their families or others.

Inspectors wroteBased on observations, interviews and document reviews, the facility failed to provide a safe and sanitary environment for residents and staff when: 1. Oxygen tanks were stored in an unlocked closet, without separation of empty and full tanks. 2. Hand washing and resident care supplies were stored under the sink in the Clean Utility Room. 3. Expired Foley insertion kits (used for insertion of a urinary catheter into the bladder) stored in the Clean Utility Room cupboard were available for use. 4. Laundry dryer area had lint buildup on the wall, around the ceiling vent, on top of the dryer and around the hinges of the door jam. 5. Two plastic bags of clean linen were being stored on the floor in a Clean Linen closet. 6. [...]

Inspectors wroteThis regulation was not met when a total of three of 25 medication pass opportunities included errors in administration technique. This resulted in an error rate of 12 percent, and medication doses not being delivered per manufacturer specifications and professional standards, with the potential of continued illness.

Inspectors wroteThis regulation was not met when a total of three of 25 medication pass opportunities included errors in administration technique. This resulted in medication doses not being delivered per manufacturer specifications and professional standards, with the potential of continued illness due to ongoing errors in technique over time.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS) were in place to carry out the functions of the food and nutrition service when: 1. There was inadequate oversight and collaboration provided by the RD for the DSS to ensure essential food service and food safety systems were in place. 2. The roles and practices of the RD and the DSS were incongruent with job descriptions, the RD contract, and professional scope of practice in the completion of essential tasks such as oversight of the kitchen, and care planning in the provision of resident care. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a comfortable and homelike environment for four residents (Residents 4, 14, 15, and 16) when the bathroom they shared was in disrepair. This failure had the potential to negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview and record review, this requirement was not met when two of 25 sampled residents' (Resident 11 and 21) nursing care plans were not revised by the interdisciplinary team after each assessment. This resulted in care plans that did not comprehensively reflect successful and unsuccessful interventions and led to repeated falls and the potential for serious injury.

Inspectors wroteBased on observation, interview and record review, this requirement was not met when three of 25 sampled residents' nursing care plans were not reviewed and revised following each assessment. This resulted in care plans that did not indicate the date and time of new interventions, or the date and time of discontinued, unsuccessful interventions, and did not tie them to any particular assessment dates. This had the potential for repeated falls and serious injury.

Inspectors wroteBased on interview, observation, this requirement was not met when there were medications available for use that were labeled past the manufacturer's expiration date. These failures could result in the accidental administration of expired medications or biologicals to residents with questionable potency or sterility.

Inspectors wroteBased on observation, interview and record review the facility failed to have an effective system in place to monitor and ensure resident meal tray accuracy and that food preferences were honored. This has the potential to result in residents receiving foods and textures non-compliant to their diet orders, food allergens, and foods identified as resident preference dislikes on their meal tray.

Inspectors wroteBased on interview and record review the facility failed to ensure the therapeutic diet for one resident was prescribed by the attending physician. This failure has the potential to result in residents receiving food that is not in an appropriate form or with appropriate nutrient content to support the resident's safety, treatment, care plan, goals and preferences.