Inspection·September 11, 2023

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 168°F. In a concurrent interview DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. 2. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter, placed pre-washed lettuce in small bowls and proceeded to peel the cucumbers and cut the tomatoes without prior washing. 3. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. During initial tour on 9/11/23 beginning at 12:30 p.m., in the kitchen, the following was observed: a. The shelving in the walk-in refrigerator was not clean. The shelves had a black fuzzy material resembling mold, on all the shelves, which was wipeable with a paper towel. Similarly, the floor was soiled with unidentified food particles and dried on liquids. There were also multiple areas that had a brown material resembling rust on the walls of the unit. The crevices and wall projections had a buildup of brown, sticky unidentified material. b. In the walk-in refrigerator there were 2 nutritional supplements in a steam pan, with ice that were undated. It was also noted there was an opened case, containing greater than 10 supplements, which were thawed and undated. In an interview on 9/12/23 at 11:45 a.m., Regional Dietary Administrative Staff acknowledged stored items needed to be labeled with a use by date. c. There were multiple pieces of equipment and areas of the kitchen that were not clean. Examples include but are not limited to the plate warmer, steam table, clear food storage containers, grey material, resembling dust, on all protruding surfaces such as light and electrical switches, plumbing and electrical cords on equipment, the floor sinks in the kitchen were not clean, food production equipment and surfaces, walls and ceilings were not clean, multiple portable ventilation units all of which were covered with unidentified food particles or a grey fuzzy material resembling dust. In an interview on 9/11/23 beginning at 4:45 p.m., DS 2 stated each employee is responsible for cleaning their own area, however, was unfamiliar whether there was a cleaning checklist. In an interview on 9/12/23 at 10:45 a.m., the Administrator stated to his knowledge there was no outside vendor contract for deep cleaning dietetic services. In an interview on 9/12/23 at 11:45 a.m., Regional Dietary Administrative Staff stated she was unable to locate any current cleaning logs but was able to offer two untitled documents dated February/March and February 2023. Cross Reference 802 4a. During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half deep steam pan as well as a one-quarter deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a interview n 9/11/23 at 5:20 p.m., DS 2 stated she turned down the temperature of the steam (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 2 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. b. It is the standard of practice to utilize and follow standardized recipes. A standardized recipe is a set of written instructions used to consistently prepare a known quantity and quality of food for a specific location. A standardized recipe will produce a product that is close to identical in taste and yield every time it is made, no matter who follows the directions (University of Pennsylvania, Introduction to Food Production and Preparation, 2023). During food production observations on 9/11/23 beginning at 2:25 p.m., DS 2 was preparing the evening meal which consisted of soy glazed pork as an entrée. DS 2 was observed placing 10 pounds of pre-cooked, diced pork, in a stock pot that contained sauteed onions. In a concurrent interview DS 2 indicated she was instructed to use a pre-cooked product. Concurrent review of departmental document titled Soy Glazed PorK guided staff to use raw pork cubes and browning them with the onions. Review of food invoices dated 9/4, 9/9 and 9/11/23 failed to indicate raw pork cubes were ordered in accordance with the standardized recipe. c. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter and proceeded to peel the cucumbers and cut the tomatoes without prior washing. d. It is the standard of practice to ensure cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution (USDA Food Code, 2023). During intermittent food production and meal distribution observations on 9/11/23 from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. 5. During initial tour on 9/11/23 beginning at 12:30 p.m., in the dry storage area, there was a plastic thermometer hanging on the wall, however the glass tube containing the red dye colored alcohol liquid, which depicts the room temperature, was missing. In a follow up observation on 9/11/23 at 1:30 p.m., it was there was a document titled Dry Food Storage Temperature Log dated September 2023 hanging on the wall next to the door. There were 2 entries for each day (morning and evening). The entries were consistently 61°F (degrees Fahrenheit). It was also noted above the log there was an electronic remote digital device that was labeled kitchen. The device indicated a reading of 61°F. In an interview on 9/11/23 at 4 p.m., Dietary Staff (DS) 1 indicated the log was filled out twice daily by the diet aides. DS 1 stated the log was put up recently and he was told to just record the temperature on the device. DS 1 stated he was not provided any additional guidance or training. Cross Reference F808 6. During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 3 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0801 indicated residents were losing weight and needed to gain fat. Level of Harm - Minimal harm or potential for actual harm In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance for food preparation, however, was interested in acquiring the skills necessary to do her job well. Residents Affected - Some Review of posted document titled Fortified Foods-Week 2 guided staff to add an extra tablespoon of whipped topping to the fresh fruit dessert. Review of the facility diet list revealed there were 5 residents with physician ordered fortified diets. In an interview on 9/12/23 beginning at 9:45 a.m., the surveyor asked the Registered Dietitian (RD)to describe her typical tasks within the facility. The RD indicated she has been with the facility approximately 2 months, spending 10-12 hours per week. The RD described her duties as clinical, completing individual nutrition assessments as well as attending weight and skin committee meetings. The RD also indicated she attempted to connect with the DFS and was told by the DFS her guidance was not necessary as she was responsible for the kitchen. The RD also stated the kitchen door had a lock that required a code, she was not given and did not have access to the kitchen, therefore has not done an evaluation of the service, any staff training or provided guidance to the DFS. On 9/12/23 at 10:20 a.m., the qualifications of the DFS were reviewed in the presence of the Administrator and the RD. The Administrator presented copies of a State University diploma indicating the DFS had a Master of Science (M.S.) in Health Sciences awarded on 12/1/91; a private school of medicine certificate indicating she was a physician, a certificate with a diploma in holistic nutrition as well as a copy of an official transcript titled fitness and nutrition. None of these degrees/certificates would meet State regulatory qualifications for the DFS. In a concurrent interview the Administrator acknowledged the facility had not completed source verification of the presented educational degrees/certificates and thought a M.S. in health sciences would meet educational qualifications. He also stated human resources (HR) would have completed official verification of any educational materials presented. In an interview on 9/13/23at 2:13 p.m., the Activities Director whose position also incorporated HR duties indicated she does not do any verification for supervisory staff and provided a corporate contact. In an interview on 9/19/23 at 2:39 p.m., Administrative Staff 2 stated it is the responsibility of individual facilities to ensure staff are qualified for the positions hired. In a written communication from the State University Campus dated 9/13/23 at 11:56 a.m., ' .without any specific information about the person, we cannot specifically verify their degree but at this time we can verify from 1987 to current there was no Masters in Health Sciences offered . Review of departmental document titled Sanitation and Food Safety Checklist dated 7/27, 6/23 and 6/1/23 revealed during the previous 3 months the Registered Dietitian (RD) identified issues with cleanliness of the kitchen floors and equipment, labeling and dating of products, storage of scoops, the janitorial area was listed as a mess on the 6/23/23 report. The 6/1/23 report also indicated there were issues with dating, however there was no indication the identified issues were addressed or resolved by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 4 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure staff competency as evidenced by lack of training and orientation of 2 of 2 dietary staff (Dietary Staff 1 and 2) members present during the abbreviated survey. Findings: 1. During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance for food preparation, however, was interested in acquiring the skills necessary to do her job well. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food for therapeutic diets. 2a. During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half deep steam pan as well as a one-quarter deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a follow up observation on 9/11/23 at 3:05 p.m., the internal temperature of the rice was 102°F. An additional observation on 9/11/23 at 5:20 p.m., revealed the temperature of the rice was 168°F. In a concurrent interview DS 2 stated she turned down the temperature of the steam table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. b. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter and proceeded to peel the cucumbers and cut the tomatoes without prior washing. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. c. It is the standard of practice to ensure cloths in-use for wiping counters and other equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 5 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0802 surfaces shall be held between uses in a chemical sanitizer solution (USDA Food Code, 2023). Level of Harm - Minimal harm or potential for actual harm During intermittent food production and meal distribution observations on 9/11/23 from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. Departmental job description titled Cook dated 12/27/21 indicated it was the responsibility of this position to prepare food in accordance with sanitary regulations. Residents Affected - Some 3. During initial tour on 9/11/23 beginning at 12:30 p.m., in the dry storage area it was noted there was a plastic thermometer hanging on the wall, however the glass tube containing the red dye colored alcohol liquid, which depicts the room temperature, was missing. In a follow up observation on 9/11/23 at 1:30 p.m., it was there was a document titled Dry Food Storage Temperature Log dated September 2023 hanging on the wall next to the door. There were 2 entries for each day (morning and evening). The entries were consistently 61°F (degrees Fahrenheit). Above the log there was an electronic remote digital device that was labeled kitchen. The device indicated a reading of 61°F. The surveyor placed a thermometer on the electrical outlet underneath the document, registering a temperature of 73°F. In an interview on 9/11/23 at 4 p.m., Dietary Staff (DS) 1 indicated the log was filled out twice daily by the diet aides. The surveyor indicated this device was a remote-control unit for the air conditioner, rather than a room temperature monitoring device. DS 1 stated the log was put up recently and he was told to just record the temperature on the device. DS 1 stated this was his first employment position and he was not provided any additional guidance or training. Facility policy titled Storage of Food and Supplies dated 2023 noted 1 .Thermometers should be placed in all storage areas and checked frequently . Review of facility training transcript for DS 1 revealed general standardized training modules, eight of which had a foodservice component. It was also noted the cumulative time spent in the eight modules was recorded as less than 2 hours. The facility was unable to provide any additional training documentation. The facility also presented a document titled Verification of Job Competency Demonstration-Diet Aides dated 2023 listed DS 1 as verbally competent, however there was no evidence to support any formal training. There was no indication on what the verbal confirmation consisted of, the specific date, time and duration of the competency determination. The competency documents for DS 1 also included a Competency Test for Cools and FNS [food and nutrition staff] dated 7/14/23. It was noted 3 of 12 questions had an incorrect answer, however the supervisor marked that 12 out of 12 questions were correct. An identical test was given to DS 2 who did not answer one question, yet the test was marked as 12 out of 12 correct. Review of the training record for DS 2 indicated the training was limited to administrative topics such as caring for those with cognitive impairment, drug diversion in healthcare, abuse and sexual harassment training. There was no documentation of any training related to dietetic services. The facility presented a Verification of Job Competency Demonstration-Cooks dated 2023, listing competency was primarily determined through verbal confirmation, however there is no indication on what the verbal confirmation consisted of or the specific date, time and duration of the competency determination. Review of positions description titled Cook indicated one year of dietary experience in a licensed facility was desired, but not necessary. The position description titled Dietary Aide indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 6 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm there was no required education or experience required and On the job training provided. While the facility provided check off lists for competency assessment there was no indication of comprehensive training for Dietary staffs 1 or 2. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 7 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on dietetic services observations, resident interview and departmental document review the facility failed to consistently follow the menu and when menus were altered did not have a method to advise residents of the changes. Failure to follow menus as outlined may result in decreased resident meal satisfaction, nutritional value of meals which in turn may result in decreased meal intake leading to weight loss, further compromising medical status. Findings: 1. During initial kitchen tour on 9/11/23 beginning at 12:30 p.m., dietary staff had just completed the noon meal service and were cleaning up. In a concurrent interview Dietary Staff 3 stated they switched the noon meal and are serving the meals intended for Thursday (9/14) today and would serve Monday ' s (9/11) meal on Thursday. The surveyor inquired the process for informing residents and the Registered Dietitian when meals were altered. DS 3 stated he was not aware of any process. Concurrent review of the menu posted in the kitchen revealed the served lunch meal should have been zesty lasagna, Italian green beans, garlic bread and rainbow gelatin cake. During initial tour of the facility on 9/11/23 beginning at 1:40 p.m., the surveyor asked Resident 1 to describe the noon meal. Resident 1 stated she was served noodles with cheese and a warm green bean salad with garlic bread and cheesecake. Resident 1 stated she has no idea what is being served at each meal. Resident 2 stated he doesn ' t know what is coming and he is getting tired of only being offered grilled cheese sandwiches as a substitute. Resident 3 stated the noon meal was pasta salad, a hot 3 bean salad, and garlic bread. In an observation on 9/11/23 at 4:34 p.m., there was an uneaten patient meal tray outside of the kitchen. The meal consisted of cooked lasagna noodles and what appeared to be broccoli and carrots. The vegetables were a combination of wax, green and kidney beans served with a slice of garlic bread. In an interview on 9/11/23 at 4:45 p.m., DS 2 stated she was unaware of why the menu was not followed as she was the evening cook, and the morning cook was gone. The surveyor also asked DS 2 if there was a system or log to record when meals were not served as written. DS 2 indicated she was not advised of any required documentation when menus were altered. In a follow up observation on 9/12/23 beginning at 9 a.m., it was noted DS 3 was not available for the next several days. During an interview on 9/12/23 beginning at 9:30 a.m., with Resident 4 stated on occasion she received a palatable meal, however many of the items she received were not on her diet. Resident 4 also stated she had no mechanism to know what was served prior to receiving her meal tray. Review of the departmental document titled Zesty Lasagna required ground turkey, spices, tomato sauce and tomato paste, various types of cheeses and lasagna noodles. Review of facility invoices dated 9/7/23 revealed the DFS had not ordered the ingredients in accordance with the Registered Dietitian approved menu, rather ordered a vegetarian lasagna convenience product. The departmental document titled Italian [NAME] Beans required frozen green beans with Italian seasoning and margarine. Review of vendor food invoices dated 9/4, 9/7 and 9/9/23 did not list frozen green beans as part of the food order. 2. On 9/11/23 beginning at 4:15 p.m., the evening meal preparation and distribution was observed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 8 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some It was noted the dinner entrée consisted of soy glazed pork, pineapple fried rice, a spinach salad, and fruit. DS 2 was observed placing lettuce, cucumbers, tomatoes, and garbanzo beans in a small dish. The surveyor asked DS 2 about the menu as it listed a spinach salad. DS 2 stated she looked for the spinach but there was none. In a follow up observation on 9/11/23 beginning at 5:15 p.m., it was also noted there were 2 residents whose meal preference was vegetarian (Resident 11 and 13) and one resident (Resident 12) whose physician ordered diet was finger foods. The resident with the physician ordered finger food diet received 4 pieces of mini corn dogs, a green salad and fruit. There were no other entrée items offered. In a concurrent interview the surveyor asked DS 2 what she was planning to plate for the vegetarian diets. DS 2 replied they would get rice, mashed potatoes, green salad, and fruit. DS 2 stated she was not trained on the preparation of vegetarian diets and on occasion she would offer tofu if it was available. Facility document titled Fall Menu Week 2 for 9/11/23 revealed residents on a finger food diet should have received bite sized soy glazed pork, fries, vegetable sticks in addition to the fresh fruit. Additionally, residents with Vegetarian diets should have received a bean and cheese taco with rice as the entrée. During entrance on 9/11/23 at 12:30 p.m., the Administrator indicated the Director of Food Services (DFS) was not in the facility, however, would return on 9/12/23. As of exit on 9/12/23 at 12:30 p.m., the DFS had not returned to the facility, as a result was unavailable for interview. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 9 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on food storage observations and resident interview the facility failed to store food in accordance with manufacturer ' s recommendations. Failure to follow manufacturer ' s recommendations may affect meal palatability resulting in decreased resident meal satisfaction. Residents Affected - Few Findings: Scientific evidence has shown that storage of bakery products such as bread and muffins change the structure of the starches, causing it to crystalize which in turn makes the bread hard and stale (Food Science, 2023). During initial tour of the kitchen on 9/11/23 beginning at 12:30 p.m., there were greater than 6 cases of baked goods including bread and desserts in the walk-in refrigerator. The manufacturer ' s guidance on each of the cases was listed as Keep Frozen at 0°F (degrees Fahrenheit) or below. During food production observation on 9/11/23 beginning at 3:30 p.m., noted DS was preparing the soy glazed pork for the evening meal. DS 2 was observed sautéing onions in oil. After a few minutes she added pre-cooked diced pork cubes. In a concurrent interview DS 2 stated she has not been trained in quantity cooking so is trying to follow the recipes by carefully measuring ingredients. DS also stated while the recipe called for uncooked pork cubes, she has only seen pre-cooked cubes. Concurrent review of the standardized recipe title Soy Glazed Pork called for raw, rather than pre-cooked, pork cubes. On 9/11/23 at 5:15 p.m., the surveyor tasted the pork. While the soy glaze was flavorful the meat tasted bland and watery. In an interview on 9/12/23 beginning at 9:30 a.m., Resident 4 stated on occasion she received a palatable meal, however overall food palatability was poor. Resident 4 gave the example that the entrée for yesterday ' s dinner (Soy glazed pork) had very little flavor. She also gave a second example that the toast this morning (9/12/23) was hard and stale. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 10 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on meal plating observation, dietary staff interview and departmental document review the facility failed to ensure the standardized menu, approved by the Registered Dietitian, was followed resulting in physician ' s orders not followed for six Residents (Residents 5,6,7,8,9 and 10) with fortified diet orders. Findings: During meal distribution observation on 9/11/23 beginning at 5:15 p.m., the evening meal consisted of soy glazed pork, pineapple fried rice, spinach salad and fresh fruit. It was noted except for the texture altered diets all residents received the same meal tray. In a concurrent interview the surveyor asked DS 2 the meaning of fortified on the tray tickets. DS 2 stated the terminology indicated residents were losing weight and needed to gain fat. In an interview on 9/11/23 at 4:30 p.m., DS 2 indicated she has been working at the facility for approximately 2 months. She also stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any additional training, was not given guidance for food preparation, however, was interested in acquiring the skills necessary to do her job well. Review of posted document titled Fortified Foods-Week 2 guided staff to add an extra tablespoon of whipped topping to the fresh fruit dessert. Review of the facility diet list revealed there were 5 residents with physician ordered fortified diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 11 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietetic services observations, dietetic staff and Registered Dietitian interview and departmental document review the facility failed to ensure meals were prepared in a sanitary manner, in accordance with standards of practice and departmental procedures as evidenced by 1) holding of foods for extended periods of time at a temperature which may promote bacterial growth; 2) vegetable preparation without prior washing; 3) use of wiping cloths that were not immersed in a chemical sanitizer; 4) undated, thawed nutrition supplements; 5) multiple kitchen areas and equipment that were not clean and 5) storage of scoops in shelf stable foods. Failure to follow standardized sanitation practice may result in bacterial growth associated with foodborne illness, cross contamination of foods, retention of expired items and create an environment that supports a vermin infestation. Findings: 1. Foods which require time/temperature control for food safety include protein-based products such as meat as well as starch-based products such as cooked rice. These foods are often called potentially hazardous foods (PHFs) and have the capability of supporting bacterial growth associated with foodborne illness. The temperature range of 41°F (degrees Fahrenheit) to 135°F is the range when PHFs are most susceptible to bacterial growth. Food kept without temperature control allows products to warm or cool as it equilibrates with the environment. Each food incurs different risks regarding the type of foodborne pathogens able to grow and the rate of growth likely to occur. For both cooling and warming conditions, growth depends on the amount of time the food spends in an optimum growth temperature range. Several factors influence the rate of temperature change in a food, such as the type of food, thickness of the food, and temperature differential between the food and its surroundings. When evaluating the safety of a 4-hour limit for food with no temperature control, products and environmental parameters must be selected to create a worst-case scenario for pathogens growth and possible toxin production (USDA Food Code Annex, 2022). During initial tour on 9/11/23 beginning at 12:30 p.m., there was a one-half sized deep steam pan as well as a one-quarter sized deep pan on the steam table containing fried rice. In a concurrent interview Dietary Staff (DS) 2 stated the item was just prepared. The smaller pan was for residents with fruit allergies and the larger one was for the remaining diets. DS 2 stated the items were for dinner meal distribution which would start at 5:15 p.m. In a follow up observation on 9/11/23 at 3:05 p.m., the internal temperature of the rice was 102°F. An additional observation on 9/11/23 at 5:20 p.m., revealed the temperature of the rice was 168°F. In a concurrent interview DS 2 stated she turned down the temperature of the steam table then turned it back up around 4:30 p.m. DS 2 also indicated she has been working at the facility for approximately 2 months. She stated her work experience was primarily in the retail sector and except for working with another cook for several days she has not received any training and was never instructed on what time to begin preparing meals. Departmental policy titled Food Preparation dated 2023 instructed staff to .5. Prepare food as close as possible to serving time .7. Hold foods prior to service for as short a time as practical. A maximum 1-hour holding time is recommended . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 12 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. During cold food production observation on 9/11/23 beginning at 4 p.m., DS 2 was observed preparing a salad for the evening meal. DS 2 obtained cucumbers and tomatoes from the walk-in refrigerator, placed them on the food production counter, placed pre-washed lettuce in small bowls and proceeded to peel the cucumbers and cut the tomatoes without prior washing. Facility policy titled Food Preparation dated 2023 listed the process for preparation of vegetables as washing fresh vegetables thoroughly under running water before cutting or peeling. 3. It is the standard of practice to ensure cloths used for wiping counters and other equipment surfaces, shall be held between uses, in a chemical sanitizer solution (USDA Food Code, 2023). During intermittent food production and meal distribution observations on 9/11/23 from 2:35 p.m., through 6:15 p.m., there were two dry [NAME] towels on the food production counter. It was noted that both DS1 and DS2 would intermittently use these towels to wipe food particles from food production surfaces. 4. Multiuse equipment is subject to deterioration because of its nature, i.e., intended use over an extended period. Certain materials allow harmful chemicals to be transferred to the food being prepared which could lead to foodborne illness. In addition, some materials can affect the taste of the food being prepared. Surfaces that are unable to be routinely cleaned and sanitized because of the materials used could harbor foodborne pathogens. Deterioration of the surfaces of equipment such as pitting may inhibit adequate cleaning of the surfaces of equipment, so that food prepared on or in the equipment becomes contaminated. Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. Studies regarding the rigor required to remove biofilms from smooth surfaces highlight the need for materials of optimal quality in multiuse equipment. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The requirement for easy disassembly recognizes the reluctance of food employees to disassemble and clean equipment if the task is difficult or requires the use of special, complicated tools. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (USDA Food Code Annex, 2022). During initial tour on 9/11/23 beginning at 12:30 p.m., in the kitchen, the following was observed: a. The shelving in the walk-in refrigerator was not clean. The shelves had a black fuzzy material resembling mold, which was wipeable with a paper towel, on all the shelves. Similarly, the floor was soiled with unidentified food particles and dried on liquids. There were also multiple areas that had a brown material resembling rust on the walls of the unit. The crevices and wall projections had a buildup of brown, sticky unidentified material. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 13 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many b. In the walk-in refrigerator there were 2 nutritional supplements in a steam pan, with ice that were undated. It was also noted there was an opened case, containing greater than 10 supplements, which were thawed and undated. There was also an undated salad plate, where the edges of the lettuce turned brown; an undated cardboard box of approximately 4 cups of sliced mushrooms that were dark brown, rather than tan colored; a to-go container dated 9/11/23 with no label; and an employee ' s commercially prepared coffee drink dated 9/7/23. In an interview on 9/12/23 at 11:45 a.m., Regional Dietary Staff (RDS) acknowledged stored items needed to be labeled with a use by date. Facility policy titled Procedure for Refrigerated Storage dated 2023 indicated .14. Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer ' s recommendations (specifications) for shelf life. c. There were multiple areas of the kitchen that were not clean. The plate warmer unit had a build-up of black grease-like material on the crevices around the plate holding chamber as well as around the rubber stoppers and indicator lights. There were greater than 5 clear food storage containers that had a build-up of labeling stickers on the outside. It was also noted the storage containers had dried, unidentified food particles. There was a buildup of grey material, resembling dust, on all protruding surfaces such as light and electrical switches, plumbing and electrical cords on equipment. The floor sinks in the kitchen were not clean. They contained unidentified food particles as well as brown and black discolorations. Floors throughout the kitchen had scattered food particles. The wall underneath the window had peeling paint exposing the drywall underneath. There were also towels on the floor underneath the wire rack adjacent to the dry storage area. The steam table was not clean, the knobs had a buildup of a tan/black stick substance resembling grease. The surfaces of the shelving beneath the steam table were also compromised as it had multiple areas of a brown material, resembling rust. Similarly, the drying mats underneath the steam table were not clean. There was a build-up of brown liquid resembling dried coffee on, behind and beneath the coffee maker. The integrity of the trays holding cleaned/sanitized serving items were not clean and were compromised in multiple areas with cuts, like a knife cut. There were multiple portable ventilation units all of which were covered with unidentified food particles and a grey fuzzy material resembling dust. The ceiling around the main vent in the kitchen was covered with grey fuzzy material, resembling dust. The light fixtures (ballast) adjacent to the window were not covered and appeared to have a retrofitted LED light strip, rather than the manufacturers specifications of fluorescent tubing with cover. The surface of greater than five baking sheets were black and brown resembling burned on oils and the byproduct of an aluminum oxidation process. On the food production surface adjacent to the steam wells there was a hole measuring approximately 1 inch in diameter in the countertop. There was a buildup of dried on food particles inside the hole. In an interview on 9/11/23 beginning at 4:45 p.m., DS 2 stated each employee is responsible for cleaning their own area, however, was unfamiliar whether there was a cleaning checklist. In an interview on 9/12/23 at 10:45 a.m., the Administrator stated to his knowledge there was no outside vendor contract for deep cleaning dietetic services. In an interview on 9/12/23 at 11:45 a.m., RDS stated she was unable to locate any current cleaning logs but was able to offer two untitled documents dated February/March and February 2023. While the department had two basic cleaning checklists, one for the cook and a second for the diet aide that included equipment surfaces such as cleaning the stove top, spice shelf, cleaning ovens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 14 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and under the steam table, cleaning drains and wiping down multiple surfaces the checklist did not fully reflect the equipment present or the necessary cleaning tasks for the department. As an example, there was no mechanism to clean the shelving or floors in the walk in or other pieces of equipment. It was also noted for the cleaning list intended for the cook cleaning tasks were limited to 2 of 7 days. Departmental document titled Sanitation and Food Safety Checklist dated 7/27/23, which was not completed by the RD, rather by the RDS, noted there were multiple areas in the kitchen that were not clean, including but not limited to baseboards, dry storage area and food production related equipment. While the RDS identified the lapses in sanitation there was no indication the facility addressed the issues. Facility Policy titled Storage of Food and Supplies dated 2023 noted 4. All shelves and storage racks .and promote easy and regular cleaning .5. Routine cleaning and pest control procedures should be developed and followed . Facility document titled Work History Report dated 9/12/23 and beginning 9/30/22 revealed the only outside work orders for the department were listed as services related to the fire suppression system. Facility policy titled Sanitation dated 2023 indicated it was the Director of Food Services (DFS) who was responsible for comprehensive training for sanitation. The policy also indicated the Maintenance Department will assist in janitorial duties the dietary employees cannot do. The policy indicated ceilings and vents were to be cleaned by maintenance staff. Additionally, the policy indicated all areas of the kitchen, and equipment will remain clean, in good repair and free from breaks, corrosions and open seams. d. In the food production area, staff were storing serving scoops inside an unlabeled/undated container, identified by DS 1 as thickener. There was also an undated/unlabeled container containing a small tan pearl sized product, identified by DS 1 as mashed potatoes. Similarly, dietary staff were storing scoops in dry cereal, and flour. There was also a bag of flour in a rolling bin that was stored in the original shipping bag. Additionally, there was a box of lasagna noodles that was opened, and not resealed leaving it susceptible to contamination. Facility policy titled Storage of Food and Supplies dated 2023 guided staff to .7. Remove foods from packing boxes upon delivery .9. Dry food items which have been opened ., noodles, etc. will be tightly closed labeled and dated . Facility policy titled Ingredient Bins dated 2023 guided staff 6.If using a bag inside the bin it is to be of food grade quality. 7. Scoops used in bins must NOT be left in the bin . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 15 of 16 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 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on facility observations and administrative staff interview the facility failed to provide a functional space for the Director of Food Services to effectively provide supervision, guidance and oversight to the day-to-day operations of dietetic services. Findings: During an interview on 9/12/23 beginning at 11:55 p.m., the Administrator indicated the workspace for the Director of Food Services (DFS) was not within the Skilled Nursing Facility, rather was in a house adjacent to the facility. In a concurrent interview Regional Dietary Staff (RDS) indicated she had worked in the facility in the past and at that time the workspace was in the Dry Food Storage area within the kitchen. The DTR also indicated at some point the facility closed off one of the exit doors in the kitchen and placed a 2-door freezer unit in front of the opening. The purpose of the DFS is to provide day to day guidance and oversight in all aspects of food storage, production, and distribution. Relocation of a workstation for the DFS, to an offsite location, would not support effective oversight and availability for consultation and guidance to food production staff, residents, or nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 16 of 16