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 Page 1 of 4 056364 056364 05/11/2023 Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405

F 0805 soft. Level of Harm - Minimal harm or potential for actual harm A review of Resident 2 ' s face sheet indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of dysphagia, dementia, and need for assistance with personal care amongst other medical conditions. A review of Physician diet order dated 10/17/21, indicated Resident 2 ' s diet was dysphagia ground meat with pureed sides. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 required one-person supervision during meals. Residents Affected - Few During an observation on 5/11/23, at 12:59 p.m., Resident 3 was eating in her room alone. Resident 3 ' s plate contained several large slices of pork with slices of carrots. The diet slip of Resident 3 indicated mechanical soft consistency. When the plate of food with large pieces of pork was shown to the DFN, she stated she will check with the cook how they prepared mechanical soft food. A review of Resident 3 ' s face sheet indicated, Resident 3 was admitted to the facility on [DATE] with a diagnosis of dysphagia and need for assistance with personal care amongst other [NAME] conditions. A review of the Physician diet order dated 2/24/23, indicated Resident 3 ' s diet was mechanical soft ground moistened texture. A review of Resident 3 ' s quarterly MDS dated [DATE], indicated Resident 3 required one-person supervision while eating. During an interview on 5/11/23, at 3:00 p.m., Unlicensed Staff L, when asked how she prepared mechanical consistency food stated, she prepared the pork as directed in the regular recipe, then she took a portion of the regular pork for chopping to make mechanical soft diets meals. Unlicensed Staff L however stated they forgot to chop the vegetables today for the mechanical soft diet. The DFN, Unlicensed Staff L, and the Registered Dietitian when asked, how it happened that three residents on modified diets were served regular consistency diets, did not provide specific answers. During a review of the policy and procedure titled: Food preparation revised 4/2016, indicated recipes are specific as to portion yield, method of preparation . The Code of Federal Regulations as stated in 42 (CFR) 483.60 (d)(3) indicated, each resident receives, and the facility provides food prepared in a form designated to meet individual needs. 056364 Page 2 of 4 056364 05/11/2023 Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405

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 observation, interview and records review, the facility failed to safely store food supplies and residents ' food in accordance with professional standards of practice when: food in the kitchen, supplies in the dry storage, and food in the utility room refrigerator for four residents (Resident 4, Resident 5, Resident 6, and Resident 7) were left to expire or not properly labelled to indicate expiry dates. This failure had the potential to cause an outbreak of foodborne illness, compromise the safety and health of residents in the facility or worse cause death of residents. Findings: During a concurrent observation and interview in the kitchen on 5/11/23, at 10:54 a.m., four pieces of muffins in a plastic bag dated opened 5/2/23 was noted on the counter by the condiments. A plastic bag containing 8 pieces of burger buns dated 2/26/23 was seen on top of the stainless container of clean and dry knives. When asked until when will the muffins be good for consumption, Unlicensed Staff L stated the muffins were good for 5 days. The burger buns in the plastic bag were taken away and discarded. During observation on 5/11/23, at 10:57 a.m., a clear plastic bag containing 3 egg sandwiches dated 5/8/23 was observed in the kitchen refrigerator. When asked until when were the egg sandwiches good to eat, Unlicensed Staff L did not respond. During an observation of the dry storage room on 5/11/23, at 11:02 a.m., two 8-ounces bottles of Nepro shake were noted labeled delivered on 2/24/23 and expired on 3/1/23. Unlicensed Staff L and the Direstor of Food and Nutrition (DFN) acknowledged the presence of the expired products among the other food in the shelves. A review of the Policy titled, Storage of food and supplies dated 2022 by Flagstone Healthcare/Healthcare menus Direct, indicated: Food and supplies will be stored properly and in a safe manner. No food will be kept longer than the expiration date on the product. Bread products not used within 5 days can be frozen. Some breads do last 5-7 days. Do not store bread in the refrigerator. On continued observation in the dry storage room on 5/11/23, at 11:22 a.m., a large can of La [NAME] chow noodles' label indicated it had expired on 5/15/22. The expired can of noodles was shown to the DFN who did not disagree with the discovery. During an observation of the refrigerator in the utility room by the Nurses station on 5/11/23, at 11:48 a.m., the following were found: 1. a vegetable salad in a paper bowl for Resident 4 dated 5/9/23, 2. left over fries for Resident 5 dated 5/7/23, 3. two plastic bags of undated meat balls, 4. pasta and salad in two separate containers without dates for Resident 6, and 056364 Page 3 of 4 056364 05/11/2023 Summerfield Health Care Center 1280 Summerfield Rd Santa Rosa, CA 95405

F 0812 5. cupcake in a zip lock for Resident 7 dated 5/7/23 Level of Harm - Minimal harm or potential for actual harm During the exit on 5/11/23, at 4:35 p.m., with the Administrator and Director of Nursing (DON), both were provided information on the findings of non-compiance. The Administrator and DON did not disagree with the findings. Residents Affected - Many A review of the Policy/procedure titled, Food for residents from outside source revised 4/2016 indicated: All items must be dated on delivery and written on the containers. and All items will be discarded after 3 days or by the manufacturer ' s expiration date. 056364 Page 4 of 4