Health inspection·December 3, 2024

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the infestation of roaches when: Residents Affected - Many 1. Live and dead cockroaches were observed in the pantry and food preparation areas in the kitchen where residents ' food was stored and prepared; 2. Pest technician recommendations for the control of the roaches were not followed; and, 3. The bedroom of two residents (Resident 1 and Resident 2), had roaches crawling in and around their beds causing Resident 1 to stop eating the food from the facility. These failures created an environment for harboring of pests and the potential for contamination of the food prepared and served. Findings: 1. During a kitchen observation on 11/27/24 at 10:08 a.m., a brown winged insect was seen climbing along an electrical cord, up and onto a shelf next to the ice machine and the coffee maker, and directly across from the refrigerator in the kitchen pantry. Insect bait traps were seen in the kitchen pantry and around the main kitchen floor near the oven and dishwasher. Dead brown winged insects were also observed around the bait traps. During an interview on 11/27/24 at 10:10 a.m., a picture and video of the browned winged insect was shown to Kitchen Staff D. Kitchen Staff D stated, That ' s a cockroach. Kitchen Staff D stated a cockroach was seen in the kitchen, but not this morning. During a continued kitchen observation on 11/27/24,10:25 a.m., a black metal security door with a screen covering leading from the kitchen directly to the outside was slightly ajar and had multiple gaps ranging in sizes from 1/4 inch to 1/2 inch. The screen covering was ripped across the bottom. and the kick plate across the bottom of the door was loose and detached from the security door. Base boards around the pantry and oven were separated from the wall and chipped. Food particles were observed on the floor under the food storage carts and in the food preparation area. A garbage can full of empty food cans was observed uncovered outside by the trash dumpster. 2. During a record review of the facility pest service reports dated 11/12/23 to 11/21/24, the summary of each of the service reports indicated the presence or infestation of German Roaches. Recommendations from the pest service reports indicated, Door gap/damage noted that allows pest access. Page 1 of 3 056430 056430 12/03/2024 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Please repair to prevent pest entry, Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. Current pest reports dated 11-18-24 and 11-21-24, indicated, There was an accumulation of food product from damaged goods noted. Please remove food product to prevent attraction by pests. During an interview on 11/27/24 at 1:30 p.m., the Dietary Supervisor I (DS I) stated there have been roaches in the kitchen and pest control was called. The DS I stated, I recommended that the facility use a different pest control service provider. During a kitchen observation with the, DS I and Kitchen Staff F on 12/3/24 at 11:30 a.m., food particles were seen on the floor around the food preparation table and behind the food tray carts. A cockroach was observed to exit the food pantry area, crawl behind the food tray carts, and crawl under the base boards. Then the cockroach exited the base boards and crawled across the kitchen floor towards the dishwasher. During a continued kitchen observation on 12/3/24 at 11:45 a.m., the screen security door in the back of the kitchen was not securely closed, the screen covering the back door was still torn on the bottom, and the kick plate on the bottom of the screen door was loosely fitted showing approximately ¼ inch gaps in the door jam. An air-conditioner in the kitchen window had ¼ inch gap opening between the air-conditioner and the window on the right side. DS I stated pests could enter the kitchen because there was no sealer around the air conditioner and the screen door was torn. 3. During an interview on 11/27/24 at 11:07 a.m., the Administrator stated she did not know of any facility pest issues, until she found out about the possible pest issue when a resident (Resident 1) filed a grievance about finding a cockroach on her meal plate which was prepared in the facility kitchen.; Resident 1 had stated she did not want to eat the food prepared by the facility. The Administrator stated Resident 1 later retracted her statement and said the cockroach was seen on her roommate ' s meal plate. The grievance record indicated; Resident 1 did not feel the food in the facility was clean. The Administrator stated after Resident 1 ' s grievance was filed on 11/15/24, she instructed the Maintenance Supervisor to keep a log of any cockroaches seen, and to notify her of each occurrence. The Maintenance Supervisor provided a binder titled Pest Citing Monitoring Binder 2024, with blank log forms, and no documentation of any observations of cockroaches. During an observation and concurrent interview on 12/3/24 at 12:25 p.m., Resident 1 was in bed asleep under the covers. Many food crumbs were noted on the floor. The edges of the baseboards next to Resident 1 ' s bed and the baseboards in the corner near the bed were not touching which created a gap of approximately one-half of an inch between them. Resident 1 ' s roommate, Resident 2, was in bed with a food tray on the overbed table with the food mostly untouched. Resident 2 stated she had seen roaches twice crawling on the wall next to her bed two weeks ago. Resident 2 stated, It made me not want to eat. Resident 2 stated Resident 1 did not want to eat here anymore because of the roaches. During an interview on 12/3/24 at 12:29 p.m., Unlicensed Staff A stated he saw roaches twice in Resident 1 ' s room about two months ago. Unlicensed Staff A stated he had seen lots of roaches in the kitchen. During an interview on 12/3/24 at 1:30 p.m., the Environmental Health Services from [NAME] County was in the facility inspecting the complaint of roaches in the kitchen. He stated he would be returning for further investigations as the facility extermination reports indicated an infestation of roaches over the last year. 056430 Page 2 of 3 056430 12/03/2024 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 12/3/24 at 2:12 p.m., Infection Preventionist (IP) stated Resident 1 had complained of a roach in her food. IP stated the resident did not have any staff come verify the roach in her food, so they were not able to confirm there actually was a roach in her food. IP stated Resident 1 had been refusing to eat the facility food. IP stated he told the resident the risks and benefits of being compliant with the facility food and buying food outside of her diet, but she still insisted the facility food was not clean. IP stated he was aware of the roach infestation at the facility and a log of roach sighting had been started. The IP stated if the door had holes in the screen, it would allow entry of pests. During a continued interview on 12/3/24 at 2:45 p.m., Maintenance Supervisor G stated he was responsible for fixing broken equipment and repairing the kitchen. During an observation and concurrent interview on 12/3/24 at 2:35 p.m., Resident 1 stated she had roaches inside her Continuous Positive Airway Pressure (CPAP, a machine used to deliver constant air pressure to help one breathe while asleep) machine, on her headboard, and in her bed. Resident 1 handed the surveyor a medicine cup with two dead roaches in it, each approximately one inch long. Resident 1 stated the two dead roaches were in her CPAP machine on Friday, 11/29/24. Resident 1 stated she was on a food strike. Resident 1 stated she had been seeing roaches in the facility since April 2024., Resident 1 stated the presence of roaches in her room was, So gross! and grimaced. During an interview on 12/3/24 at 3:06 p.m., Unlicensed Staff B stated he saw a roach one month ago in Resident 1 ' s room. Unlicensed Staff B stated it was on the door as he went in. During an interview on 12/3/24 at 3:16 p.m., Unlicensed Staff C stated she had seen, a lot of roaches in the facility, mainly in the kitchen and in Resident 1 ' s room, mainly inside her CPAP machine. Unlicensed Staff C stated the CPAP machine was on all the time at night, and the roaches liked the heat. Unlicensed Staff C stated one month ago they had seen roaches in Resident 1 ' s room twice, both times it was inside the CPAP machine. During a telephone interview on 12/4/24 at 11:15 a.m., Exterminator J from a local company confirmed he was the exterminator who provided pest control services at the facility. When asked how long the roach infestation had been going on he stated for about 1-year. Exterminator J stated he has been treating the laundry room and, trying to get the kitchen under control with the roaches. Exterminator J stated, the recommendations from the reports have not been corrected by the facility. He stated he would be going back to the facility this week and doing after hours spray treatments. Exterminator J stated the facility was instructed on how to clean the kitchen after the spraying., Exterminator J also stated, he told the Dietary Supervisor what needed to be cleaned in the kitchen. Review of the facility ' s policy and procedure titled, Pest Control RMG 020-00, dated [DATE], indicated, 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 056430 Page 3 of 3