Manresa Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen personnel were properly trained on checking the dishwasher sanitizer, when the manufacturer's instruction of the test strip was not followed. This failure had the potential to spread food-borne illness to everyone who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure stacked, clean food service equipment was air dried prior to stacking them. This failure had the potential of any one consuming food prepared in the kitchen contracting a food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:An incorrect isolation precaution (a set of practices used in healthcare settings to prevent the spread of germs from one person to another) signage was posted outside Resident 61's entrance door. CNAs were helping more than one resident at a time to eat, without using hand hygiene between different residents. These failures had the potential to spread infections to residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two out of 17 residents (Resident 10 and Resident 12) had an order from the physician allowing the administration of medications listed as allergies in the residents' medical records. This failure had the potential to create adverse outcomes for the affected residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary medication for one of 15 sampled residents (Resident 3) when Resident 3 received Acyclovir (an antiviral medication) without a clear indication. This failure had the potential for unnecessary medication administration for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to submit a report of a full investigation to the State Survey Agency (SSA) five days after sending an initial report of an altercation between two residents for one of three reported incidents reviewed. This failure resulted in the SSA potentially not receiving a full report of the incident. Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with a diagnosis of dementia (a disorder of the brain which causes loss of memory and function) and heart failure (a disease which affects the heart's ability to pump blood). Review of Resident 2's clinical record indicated Resident 2 was admitted on [DATE] with a diagnosis of Alzheimer's disease (a specific type of dementia) and polyneuropathy (a disorder of the nerve endings which causes feelings of numbness and tingling in the toes and fingers). [...]

Inspectors wroteBased on observations, interviews, and document reviews the facility failed to ensure overall systems in food and nutrition services were maintained according to standards of practice and facility policy when: 1) The Food and Nutrition Services Department staff were unable to correctly demonstrate kitchen tasks in food safety, service, and sanitation tasks, 2) The ice machine was not cleaned according to manufacturer's guidelines, and a 3-compartment sink system for cleaning, rinsing, and sanitizing was not established for operation. 3) Facility approved menus and recipes were not followed for residents with therapeutic diets. 4) The Certified Dietary Manager (CDM) did not have the required state of California education requirements on regulations for dietetic services. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure staff performed their job functions competently according to standards of practice when: 1) Two kitchen aides did not know how to properly test the level of dishwasher sanitizer. 2) One kitchen aide dumped trash can debris into the wash/rinse compartment of the 2-compartment sink with dirty dishes in them. 3) One cook did not know how to properly calibrate thermometers meant to test food temperatures. 4) One cook did not properly verbalize the cooldown process. 5) One prep cook/diet aide did not know how to properly prepare cold foods such as tuna salad or chicken salad. 6) One kitchen aide was seen washing his hands with only water after taking a bag of garbage out of the kitchen, and then touching dishes needing to be cleaned. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food safety practices were followed according to facility policy and standards of practice when: 1) A dirty cooking utensil was stored with clean utensils. 2) The ice machine reservoir tray had black colored debris in the tray and was not sanitized correctly. 3) Food in the walk-in refrigerator was not labeled with an opened-on date and use-by date. 4) The kitchen did not have a 3-compartment sink system for manually washing, rinsing, and sanitizing dishes. 5) The 2-compartment sink the kitchen uses for dishwashing does not have an air gap which prevents backflow of dirty water. 6) The Low temperature dish machine did not reach 120 degrees Fahrenheit consistently over three cycles. These failures had the potential to expose vulnerable residents to potential contaminants that may cause food borne illnesses. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ) staffing information to the Centers for Medicare and Medicaid Services (CMS), for the last quarter of 2023 (October, November, & December). This failure to submit the required data, staffing hours and census information, can inhibit the facility's ability to determine an adequate level of staff is working at a given time, leading to inadequate care of residents.

Inspectors wrote2a. During an observation on 4/8/24, at 10:24 a.m., Resident 2 was sitting in the wheelchair, asleep, and receiving supplemental oxygen in her room. There was no date on the oxygen humidifier bottle. During an observation on 4/9/24, at 12:37 p.m., Resident 157 was observed sitting in the wheelchair, and receiving supplemental oxygen in her room. There was no date on the oxygen humidifier bottle. Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure as well as professional standards of practice regarding oxygen administration for 7 of 8 sampled residents (Resident 2, Resident 10, Resident 16, Resident 23, Resident 25, Resident 46, & Resident 157) when: 1. Resident 23 did not have an oxygen in use sign outside his room 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow standardized recipes and menus approved by the facility's Registered Dietitian (RD), according to facility policy and standards of practice when: 1) Rice was served instead of noodles for the liberal renal therapeutic diet, 2) The puree diet did not receive an appropriate pureed vegetable for the lunch meal. These failures had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for 4 of 7 sampled residents (Residents 155, 37, 33, and 40) when: 1. Registered Nurse I (RN I) did not perform hand hygiene when handling Resident 155's peripherally inserted central catheter (PICC, used to deliver medications and other treatments directly to the large central veins near the heart); and 2. There were no personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) carts outside residents' room (Residents 37, 33, and 40). These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policies on medication self-administration (resident takes medication without staff assistance) for one sampled resident (Resident 157) when the facility did not determine that the resident was clinically appropriate and safe to self-administer medications and did not remove an expired medication from the resident's bedside. These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (identifies residents' concerns and outlines the care and services needed to meet their needs) to address smoking for one of three sampled resident (Resident 255). This failure had the potential to result in the inability to identify the resident's individualized care issues and implement a person-centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 15 residents (Resident 30) remained free from accident hazards due to the use of bed rail (side rail) when Resident 30 had the half bed rail raised up without bed rail assessment. This failure had the potential to put Resident 30 at risk for entrapment and serious injury.

Inspectors wroteBased on observations, interview, and record review, the facility failed to have a medication error rate of less than 5% as evidence of 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for one of 5 residents (Resident 2) observed during medication administration. Resident 2's eye medications were not administered in accordance with the facility's medication administration guidelines and accepted professional standards of practice. These failures resulted in medications not given as per accepted professional standards of practice, which may negatively affect the resident's health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food and utensils were stored and prepared in accordance with professional standards for safety, when pans (metal container) were not air dried before storing, storage rack for the knives was uncleaned and floor inside the pantry was left wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness (illness caused by food or water contaminated with bacteria, viruses, parasites or toxins) and cross contamination of food that could affect the 54 residents residing and consuming food at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when : 1. Staffs were double masking using an N95 mask (disposable filtering facepiece respirator); 2. For Resident 38, her enteral feeding bag did not have a label and was left open; 3. A kitchen staff was not wearing proper N95 mask; and 4. A staff did not perform hand hygiene in between task during medication pass observation. These failures had the potential to spread infections, and compromise resident's health and safety especially when the facility had on-going Covid -19 outbreak (a new strain of virus that can cause mild to severe respiratory illness).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for two of 14 sampled residents (Resident 8 and 23) when: 1. for Resident 8, fall care plan was not updated and properly implemented; 2. for Resident 23, care plan for a new diagnosis was not developed. These failures had the potential for inaccurate development and implementation of a personalized and resident-centered care plans that would address the residents' identified concerns and needs.

Inspectors wroteReview of Resident 6's admission record indicated he was admitted to the facility with a diagnosis of urinary tract infection (UTI). Review of Resident 6's minimum data set (MDS, an assessment tool) dated 7/3/22, indicated he had a BIMS ( Brief Interview for Mental Status) of 2 (0-7 severe cognitive impairment ) and he was total dependent with personal hygiene. During an observation and concurrent interview with registered nurse B (RN B) on 7/28/22 at 2:52 p.m., Resident 6's nails have black residue under his long fingernails. RN B stated Resident 6 was not diabetic and acknowledged his fingernails were dirty and need to be cleaned and trimmed . During an interview with the certified nursing assistant C (CNA C) on 7/28/22 at 3:00 p.m., she stated she was assigned for Resident 6 on 7/28/22 and she checked his nails. CNA C stated she can clean the nails but she needed to ask his nurse. [...]