Vibra Hospital of Northern California D/P SNF

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.