Health inspection·February 17, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure resident food was stored in a safe and sanitary manner. Residents Affected - Some This failure had the potential to cause infection and food borne illness to the residents that received food from the kitchen. Findings: During an observation on 2/12/24, at 10:17 a.m., the dry food storage and freezer room was observed. Sixteen prune juice cups, 118 mL (milliter) each, had a manufacturer's use by date of 11/1/23, were stored on a shelf. An open box of bananas, a container with 17 quarts of brown rice, a container with 9 quarts of white rice, and a container with 48 cups of flour were stored on shelves about 3.5 inches above floor. Freezer 3 had a box of frozen dinner rolls that were unsealed and had a manufacturer's use by date of 1/15/24. Freezer 2 had a 3-gallon container of strawberry ice cream with an unsealed ripped lid. Freezer 1 had a 15-pound box of fish fillets and an opened bag of frozen chicken unsealed, a 300-slice box of bacon unsealed with a use by date of 1/27/24, beef that was not labeled with date, and frozen meat and a bag of chopped meat that was unlabeled and undated. During a concurrent observation and interview on 2/12/24, at 11:02 a.m., with Dietary Manager (DM) the dry storage and freezer room was observed. DM stated anything expired and without a label should have been thrown out. DM did not know the minimum storage height for food. DM stated unsealed frozen food in freezer was ok. During an interview on 2/13/24, at 2:00 p.m., with Registered Dietician (RD), RD stated frozen food in freezer should always be sealed and it was important to prevent freezer burn, maintain the quality, texture, and palatability of the food, and to prevent infection and food borne illness. RD stated food should have been stored at least 6 inches above the floor to prevent contamination from pests, infection, and food borne illness. RD stated it was the facility's policy to label all food items with received, opened, and use by date. RD stated it was important to throw out unlabeled, undated, and expired food because it could have caused the residents to get infection and food borne illness. During a review of the facility's policy and procedure (P&P) titled, Freezer Storage, dated 2023, the P&P indicated, Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. The P&P indicated, All frozen foods should be labeled and dated. During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055562 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)