Health inspection·May 11, 2023

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and records review, the facility failed to provide food of appropriate consistency for 3 of 12 residents (Resident 1, Resident 2, Resident 3) on modified consistency diets, when Resident 1, Resident 2, and Resident 3 were served regular consistency pork for lunch. This failure had the dangerous potential to cause choking, or worse, death of residents from choking or aspiration. Findings: During an observation at the facility dining room on 5/11/23, at 12:41 p.m., Resident 1 was seated with three other residents around a table eating his lunch. Resident 1 ' s meal consisted of regular Hawaiian pork, fried rice, and ginger carrots. Resident 1 was assisted by CNA A. When this Surveyor stated the pork pieces were bigger than mechanical chopped size pork, CNA A disagreed the pork was not chopped. The diet slip lying by Resident 1 ' s plate indicated Resident 1 should be provided mechanical soft diet. Resident 1 ' s diet was confirmed from www.residentdietsystem.com provided by the Director of Food and Nutrition (DFN) dated 5/11/22, indicating Resident 1 should have large meat portion of mechanical soft consistency. A review of Resident 1 ' s face sheet (one-page summary of important information about a patient, including patient identification, insurance status, and other pertinent information) indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of Parkinson ' s disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysphagia (difficulty or discomfort in swallowing), dementia (loss of cognitive functioning thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and Alzheimer ' s disease (brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), amongst other conditions. A review of Physician diet order dated 8/8/22, indicated Resident 1 ' s diet texture was mechanical soft. A review of Resident 1 ' s Minimum Data Set (MDS - a part of a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes providing a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 3/11/23, indicated Resident 1 required extensive one-person assistance to eat and had a swallowing disorder manifested by loss of liquid/solids from mouth when eating or drinking, coughing, or choking during meals or when swallowing medications. During an observation in the dining room on 5/11/23, at 12:45 p.m., Resident 2 was eating regular Hawaiian pork, fried rice, and ginger carrots. The diet slip found by the side of Resident 2 ' s plate indicated dysphasia ground (ground meat, puréed sides). When this Surveyor stated Resident 2 ' s Hawaiian pork was regular consistency, CNA B looked at the plate and stated, maybe the meat is (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 4 Event ID: 056364 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 056364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405 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)