Health inspection·August 8, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to provide a clean and sanitary environment for the residents who used the dining area and residents who ate facility prepared meals when a bird cage containing 4 birds was not kept clean and sanitary, and was placed next to the walkway of the two (2) kitchen doors where food carts carrying resident meals pass through for a census of 118 residents. This failure had the potential to result in cross-contamination of facility prepared resident meals and could spread infection and/or other bird-related diseases to residents, facility staff, and visitors. Findings: During a telephone interview on 8/7/24 at 12:35 p.m. with Responsible Party (RP) 1, RP 1 stated, .They [facility] have birds in the dining area, near the kitchen door, and it's [bird cage] dirty. It's [bird cage] not clean, those [dirt] might get into their [residents] food . During an observation on 8/8/24 at 12:12 p.m., at the dining area during lunch mealtime, a black metal birdcage containing 4 birds was observed on the north side wall of the dining area next to the walkway of the two kitchen doors. On the bottom of the birdcage was a white plastic container and pile of paper, both were stained with multiple scattered specks of brown-to-whitish material. On the floor, surrounding the birdcage area, was multiple scattered feathers, specks of brown-to-whitish material and seed-like dirt. Two (2) feet away from the birdcage was a dining table currently being used by two (2) residents for their lunch meal. Two (2) food carts were observed to be coming out of the kitchen doors carrying resident's lunch meals and used the walkway next to the birdcage. A review of Resident 4's clinical record indicated Resident 4 was admitted January of 2024 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems) and asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). A review of Resident 4's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 7/22/24, indicated Resident 4 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 4 had an intact cognition. During a concurrent observation and interview on 8/18/24 at 12:22 p.m. with Resident 4, at the dining area during lunch mealtime, Resident 4 confirmed that the birdcage placed next to the walkway of the kitchen doors was not kept clean and sanitary. Resident 4 stated, .The dirt on the bottom, that concerns me because sometimes it gets to the next table and what concerns me is the food on the (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: 056410 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 056410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitney Oaks Care Center 3529 Walnut Avenue Carmichael, CA 95608 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)