Health inspection·May 20, 2022

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a safe discharge plan for one of one sampled residents (Resident 26) when 1) the facility did not discuss Resident 26's facility-initiated discharge plan with the resident's daughter or obtained the daughter's agreement to care for Resident 26, and 2) the facility-initiated discharge plan to discharge Resident 26 to a location that was not determined by the choice or the best interests of Resident 26. This failure resulted in Resident 26 feeling very upset and had to go through an appeal process. Findings: The intake information sheet dated 4/28/22 indicated that the Department (the California Department of Public Health) received an anonymous complaint on 4/28/22 regarding a involuntarily discharge of a resident. The complaint information included that the resident had gone through an appeal process with the Office of Administrative Hearing and Appeals. The resident was granted to be remained in the facility due to the facility did not provide the resident with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. The complaint information also included that the facility did not obtain the daughter's agreement to allow her mother to reside with her in another state. During a review of Resident 26's admission Record, dated 3/15/18, indicated she had been admitted to the facility on [DATE] originally and had been readmitted to the facility on [DATE] with a history of right artificial knee replacement and difficulty walking. During a concurrent interview and record review on 4/28/22 at 2:00 p.m., with the Social Services Director (SSD), Resident 26's Facility-Initiated Discharge Notice, dated 3/1/22 was reviewed with the SSD. The SSD stated Resident 26's daughter would provide care to Resident 26 in her home. The SSD stated Resident 26 was no longer eligible for covered skilled nursing services and neither Resident 26 nor her family were able to pay privately to remain at the facility. During a review of Resident 26's Social Services Progress Notes, dating from 2/2/22 to 3/29/22 indicated there were no documented encounters where Resident 26's daughter had agreed to provide care and housing for Resident 26. The SSD could not explain how Resident 26's daughter was indicated to be agreeable to providing housing and care to Resident 26. The SSD stated, there was nothing else to be done and did not know what to do since Resident 26 was unable to pay for her stay at the facility and other measures for housing and care were not available. During an interview on 4/28/22 at 4:11 p.m., with Resident 26, she stated she was very upset when she received a paper from the SSD and the paper indicated Resident 26 would be living with her Page 1 of 27 056483 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daughter out of state. Resident 26 stated both of her daughters did not have the space nor the time to care for her and she did not want to be a burden to her daughters. Resident 26 stated, she felt comfortable and safe living at the facility. During a review of the facility's policy and procedure titled, Transfer or Discharge Notice, dated 2016, the P&P indicated, 3. The resident and/or representative (sponsor) will be notified in writing of the following information: .c. The location to which the resident is being transferred or discharged ; .10. At the time of notification, the facility will provide each resident and responsible party with the following information: a. The plan for the transfer and adequate relocation of resident. B. The date by which the transfer/relocation of the resident will be completed; and c. Assurances that the resident will be transferred to the most appropriate facility or setting to meet his or her needs in terms of quality, services, and location. 11: In determining the transfer location for a resident, the decision to transfer to a particular location will be determined by the needs, choices and best interests of that resident. 056483 Page 2 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure residents received the necessary care and services to ensure resident's abilities to perform Activities of Daily Living did not decline when Restorative Nursing Assistant (RNA) services (RNAs perform range of motion exercises and strengthening exercises) were not provided as ordered for four Residents (Resident 4, Resident 84, Resident 28 and Resident 23). Residents Affected - Some This failure had the potential to result in decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: 1. During an observation and interview on 5/17/22, at 8:34 a.m., Resident 4 was observed seated in his wheelchair at his bedside. He stated he had not had and Physical Therapy (PT) or RNA services for 6 months or longer. He stated the facility had a lot of problems and one day the PT just stopped. Resident 4 stated he was informed he was not getting any PT or exercises (RNA services) because the facility had money problems. He stated a year ago he had PT and was walking, but he is not walking now. Resident 4 stated he was worried about the care he was receiving at the facility, and Was scared he was to never going to be able to get better. A review of a document titled admission RECORD, for Resident 4, indicated he was admitted [DATE], with Diagnoses that included Chronic Obstructive Pulmonary Disease, (A type of progressive lung disease that cases airflow blockage and breathing related problems.), Obesity, Muscle Weakness and Lack of Coordination. A review of Resident 4's Minimum Data Set (MDS) (A health screening and assessment toll used for all Residents) indicated a Brief Interview for Mental Status (BIMS) score of 15 (BIMS is an assessment used to get a quick snapshot of how well you a resident is functioning cognitively at the moment. Residents with a BIMS score of 8-12 considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15). Review of a facility document for Resident 4, titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated March 2022, indicated he received RNA services once a week on 2/2/22 and 2/8/22. The document indicated for April, Resident 4 had 10 minutes of RNA therapy on 4/4/22 and had no other RNA services documented for April or May. 2. During a lunch observation on 5/16/22, at 1:10 p.m., Resident 84 was observed to eat her lunch with her fingers. No staff were observed to assist her. A review of a document titled admission RECORD, for Resident 84, indicated she was admitted [DATE], with Diagnoses that included Multiple Sclerosis (A degenerative disease of the brain and spinal cord that disrupts the signals from the brain to the body that results in paralysis.). Diagnoses with onset date of 7/16/21 indicated Contracture , Right Wrist, Left Wrist, Left Hand, Muscle Weakness, Abnormal Posture. 056483 Page 3 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a facility document for Resident 84, titled FAX TRANSMITTAL SHEET, dated 12/22/21, indicated To Dr. [NAME] . RNA program for PROM (Passive Range of Motion) to U.E.'s (Upper Extremities), and L.E's, (Lower Extremities) x 5 (5 times) 3 months, 2 x's a week .Renewed 3/22/22. Review of a Physician's Order document titled Order Summery Report, dated 2/27/22, indicated a doctor's order for RNA program: PROM for UE's & LE's 2 X / wk X 3 months one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 2/22 indicated Resident 84 received RNA services once a week on 3/1/22 and 3/7/22. On 4/3/22, the document indicated Resident 84 had 10 minutes of RNA therapy, and no other RNA services documented for the month of April or May. 3. During an interview on 5/19/22, at 12:35 p.m., Resident 28 stated the facility was really short of staff. He stated they moved the RNA to CNA duties, and he has noticed he was stiffer and was worried about losing his strength. A review of Document titled admission RECORD, for Resident 28, indicated he was admitted [DATE], with Diagnoses that included Quadriplegia (A condition paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso.), Cerebral Palsy (A group of movement disorders that include poor coordination and muscle control.), Muscle Weakness. A review of Resident 28's MDS indicated a BIMS score of 15. Review of a facility document for Resident 28, titled FAX TRANSMITTAL SHEET, dated 1/26/22, indicated To Dr. [NAME] . Continue RNA program for PROM to LE's, 2 x's a week, x 3 months. Renew April 26, 2022. Review of a Physicians Order document titled Order Summary Report, dated 3/30/22, indicated RNA Program: PROM to LE's 2 X / wk X 3 month one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 3/22 indicated Resident 28 received RNA services once a week on 3/3/22 and 3/8/22. On 4/1/22, the document indicated Resident 28 had 15 minutes of RNA therapy, and no other RNA services document for the month of April or May. During an interview on 5/18/22, at 1 p.m., Unlicensed Staff K and Unlicensed Staff L stated their duties included checking the residents every two hours and repositioning them. They stated they did not assist residents with exercise. They stated the risk to residents if they do not get repositioned was sores or contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a phone interview on 5/19/22, at 8:49 a.m., the Director of Physical Therapy stated she started in April 2022. She stated she was aware the facility used to have an RNA but not now. She stated the RNA had been reassigned to work as a Certified Nursing Assistant (CNA). She stated there were no RNA services being performed in the facility. Director of Physical Therapy stated seven Residents who were supposed to have RNA services were not receiving it. She stated the risk to residents when they do not receive RNA services was decline in walking, potential contractures, inability to function independently for feeding themselves. She stated she was unaware the facility had 21 residents with diagnosed contractures and six residents had developed them after admission. She stated residents could have developed contractures from lack of exercise and positioning and lack of an RNA and staffing may have contributed to that. During a phone interview on 5/19/22, at 9:59 a.m., the Medical Director stated the facility used to have full time PT and Occupational Therapy (OT), but the facility ran out of money. He stated about 6 months ago, the facility prioritized nursing care and PT was not a priority. Medical Director 056483 Page 4 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated Rehabilitation services was essential, but lack of staffing was an issue. He stated during COVID there were no resident admissions and so there was no work for PT. He stated the RNA was pulled to do CNA duties around 3 months ago. Medical Director stated two times a week for PT or RNA was sub-optimal, but it was better than nothing. He stated if someone has a risk of decline I would order Rehabilitation services 3 times a week. He stated if someone not receiving PT services or Rehabilitation services physical decline would have been inevitable. During an interview on 5/19/22, at 10:53 a.m., Licensed Nurse P stated there was no RNA anymore. Licensed Nurse P stated RNA was currently doing CNA work only. Licensed Nurse P stated finding staffing was so difficult that a decision was made to use RNA as a CNA for direct resident care. Licensed Nurse P stated the lack of staffing increased the workload and walking residents or exercising was not done, which would contribute to contractures or decline in Activities of Daily Living (ADL)(Being able to eat, wash, shower, brush teeth, transfer to a toilet or wheelchair independently or with minimal assistance). A review of a facility Policy and Procedure (P&P) titled Restorative Nursing Services, revised July 2017, indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. A review of a facility document titled Restorative Nursing Program, dated 5/28/13, indicated Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of patient's optimum level of function.These services must be performed daily.Restorative Nurse's Aide Is responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines.Program Structure 1. Frequency of treatment: daily, 7 x/wk., QD(every Day). 2. Conducted by RNA on a one-to-one basis . 4. During an observation on 5/17/22, at 9:30 a.m., in the hallway, Resident 23 was in his wheelchair. Resident 23 propelled himself by pushing with one foot. Resident 23 propelled himself via wheelchair back and forth from the nurse station to the facility entrance. Resident 23 continued to go back and forth until the lunch meal was served at 12:30 p.m During a review of the clinical record for Resident 23, the Physician Orders, dated 2/15/22, indicated Resident 23 had an order for the Restorative Nursing Assistant (RNA) program. The order indicated Resident 23 would ambulate with a hemi walker (a small, one-handed walker that is intended to be used by persons that have one-half of their body weakened) 2 times a week. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 2/22, indicated Resident 23 was participating in the RNA program. The record indicated Resident 23 received 3 out of 4 session opportunities. The record indicated 1 session was not carried out due to the equipment not being available. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 3/22, indicated Resident 23 was participating in the RNA program. The record indicated Resident 23 received 8 out of 10 session opportunities. The record did not provide documentation to show a rationale for the 2 missed sessions. During a review of the clinical record for Resident 23, the Restorative Nursing Program Activity Record, dated 4/22, indicated Resident 23 was participating in the RNA program until the sessions were stopped. The record indicated Resident 23 received 4 out of 8 session opportunities. There was no 056483 Page 5 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0676 documentation to indicate why the physician's order was no longer carried out. Level of Harm - Minimal harm or potential for actual harm During an interview with Licensed Nurse Z (LN Z), on 5/20/22, at 1:03 p.m., she stated Resident 23 looked so sad. LN Z stated the facility had paused the RNA program so Resident 23 was not getting to walk. LN Z stated over time he will lose function. LN Z stated Resident 23 asked Unlicensed Staff Y (UNLS Y, who was a RNA) for a walking session, but UNLS Y had to refuse because she was assigned to work on the floor providing direct care. Residents Affected - Some 056483 Page 6 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure enough staff to meet the needs of residents, when Restorative Nursing Assistant (RNA) services were discontinued and used RNA staff as a Certified Nursing Assistant (CNA). This failure had the potential to result in resident falls, skin breakdown, and residents decline of resident's Activities of Daily Living (ADL)(The ability to be able to eat, wash, shower, brush teeth, walk, transfer to a toilet or wheelchair independently or with minimal assistance.), and contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: (Reference F676) 1. During an observation on 5/16/22, at 11:05 a.m., the white board in Nurse Station 1 indicated Licensed Nurse P, Unlicensed Staff Q, Unlicensed Staff R, and Unlicensed Staff S on duty. During an interview on 5/16/22, at 12:36 p.m., Resident 4 stated staffing was really short. He stated the short staffing had resulted in less therapy for him. He stated he had gotten much weaker after he did not have therapy. He stated when he was admitted , he could stand but now he cannot. Resident 4 stated there are only 2 CNAs scheduled during the day. During an observation on 5/16/22, at 12:35 p.m., Resident 4 was observed seated in his wheelchair at his bedside eating lunch. At 3:46 p.m. he was observed seated in his wheelchair at his bedside. At 4:15 p.m., he was observed seated in his wheelchair at his bedside. During an observation and interview on 5/17/22, at 8:34 a.m., Resident 4 was observed seated in his wheelchair at his bedside. He stated he had not had and Physical Therapy (PT) or RNA services for 6 months or longer. He stated the facility had a lot of problems and one day the PT just stopped. Resident 4 stated he was informed he was not getting any PT or RNA exercises because the facility had money problems. He stated a year ago he was walking, but he is not walking now. Resident 4 stated he was worried about the care he was receiving at the facility, and Was scared he was to never going to be able to get better. A review of a document titled admission RECORD, for Resident 4, indicated he was admitted [DATE], with Diagnoses that included Chronic Obstructive Pulmonary Disease, (A type of progressive lung disease that cases airflow blockage and breathing related problems.), Obesity, Muscle Weakness and Lack of Coordination. A review of Resident 4's Minimum Data Set (MDS) (A health screening and assessment toll used for all Residents) indicated a Brief Interview for Mental Status (BIMS) score of 15 (BIMS is an assessment used to get a quick snapshot of how well you a resident is functioning cognitively at the moment. Residents with a BIMS score of 8-12considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15). 056483 Page 7 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0725 Level of Harm - Minimal harm or potential for actual harm Review of a facility document for Resident 4, titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated March 2022, indicated he received RNA services once a week on 2/2/22 and 2/8/22. The document indicated for April, Resident 4 had10 minutes of RNA therapy on 4/4/22 and had no other RNA services documented for April or May. Residents Affected - Some 2. During an interview on 5/16/22 at 1:16 p.m., Resident 17 stated staffing could be pretty short. 3. During a lunch observation on 5/16/22, at 1:10 p.m., Resident 84 was observed to eat her lunch with her fingers. No staff were observed to assist her. A review of a document titled admission RECORD, for Resident 84, indicated she was admitted [DATE], with Diagnoses that included Multiple Sclerosis (A degenerative disease of the brain and spinal cord that disrupts the signals from the brain to the body that results in paralysis.). Diagnoses with onset date of 7/16/21 indicated Contracture , Right Wrist, Left Wrist, Left Hand, Muscle Weakness, Abnormal Posture. Review of a facility document for Resident 84, titled FAX TRANSMITTAL SHEET, dated 12/22/21, indicated To Dr. [NAME] . RNA program for PROM (Passive Range of Motion) to U.E.'s (Upper Extremities), and L.E's, (Lower Extremities) x 5 (5 times) 3 months, 2 x's a week .Renewed 3/22/22. Review of a Physician's Order document titled Order Summery Report, dated 2/27/22, indicated a doctor's order for RNA program: PROM for UE's & LE's 2 X / wk X 3 months one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 2/22 indicated Resident 84 received RNA services once a week on 3/1/22 and 3/7/22. On 4/3/22, the document indicated Resident 84 had 10 minutes of RNA therapy, and no other RNA services documented for the month of April or May. 4. During an interview with Resident 28, on 5/19/22 at 12:35 p.m., he stated there was a shortage of staff that resulted in the facility taking away the RNA program. A review of Document titled admission RECORD, for Resident 28, indicated he was admitted [DATE], with Diagnoses that included Quadriplegia (A condition paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso.), Cerebral Palsy (A group of movement disorders that include poor coordination and muscle control.), Muscle Weakness. A review of Resident 28's MDS indicated a BMS score of 15. Review of a facility document for Resident 28, titled FAX TRANSMITTAL SHEET, dated 1/26/22, indicated To Dr. [NAME] . Continue RNA program for PROM to LE's, 2 x's a week, x 3 months. Renew April 26, 2022. Review of a Physicians Order document titled Order Summary Report, dated 3/30/22, indicated RNA Program: PROM to LE's 2 X / wk X 3 month one time a day every Tue, Thur for RNA program. Review of a document titled RESTORATIVE NURSING PROGRAM ACTIVITY RECORD, dated 3/22 indicated Resident 28 received RNA services once a week on 3/3/22 and 3/8/22. On 4/1/22, the document indicated Resident 28 had 15 minutes of RNA therapy, and no other RNA services document for the month of April or May. During an interview on 5/17/22, at 4:32 p.m., the Administrator stated staffing was very hard to provide in this area, and to fill the empty nursing shifts, the Minimum Data Set Nurse (MDS) (A health status screening and assessment tool used for all Residents.), and the IP Nurse were pulled off their assignments to provide direct patient care. The Administrator was asked to explain the nursing schedule. She stated MDS nurse did the schedule and calculations, and had the documents, but he worked 056483 Page 8 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0725 the Night shift last night and would not be available until 5/18/22. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/18/22, at 1 p.m., Unlicensed Staff K and Unlicensed Staff L stated their duties included checking the residents every two hours and repositioning them. They stated the risk to residents if they were not repositioned, the resident could develop skin breakdown or contractures (A condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Unlicensed Staff K and Unlicensed Staff L stated they turned all the residents, unless they declined, and then they told the nurse. Residents Affected - Some During an interview with Unlicensed Staff Q on 5/18/22 at 4:02 p.m., she stated usually there are three CNA's during the day. She stated today she was working 2:30p.m. to 11 p.m., but she usually worked day shift. During a phone interview on 5/19/22, at 8:16 a.m., Director of Physical Therapy stated the facility used to have a Restorative Nursing Assistant (RNA) program, but not right now. She stated the residents were not receiving RNA services because the trained RNA had to work as a Certified Nursing Assistant. She stated the Physical Therapy was short staffed and she had to use the Occupational Therapist to complete assessments. She stated she could not screen all the residents. She stated the risk of not having RNA services was Resident decline as exhibited by development of contractures, muscle weakness, atrophy, lack of positioning, lack of exercise. She stated the shortage of all staff contributed to risk of Resident decline. During a phone interview on 5/19/22 at 9:59 a.m., the Medical Director stated they used to have full time PT and OT, but because of COVID and hiring Travelers, the facility ran out of money. He stated the facility prioritized nursing care over PT and used the RNA as a CNA to provide direct patient care. He stated the facility lost PT department about 6 months ago. He stated if residents did not receive PT or RNA services, there was a risk of residents experiencing physical decline would be inevitable. Medical Director stated he was not sure when a change took place but there used to be two nurses everyday and now there is frequently only one licensed nurse. He stated having only one licensed nurse means they have less time to do assessments, spend time with residents, doing just the basic stuff. During an interview and record review with MDS on 5/19/22, at 10:45 a.m., he stated he was responsible for scheduling staff. He stated the facility prioritized resident care. MDS stated staff worked overtime, double shifts, and split shifts to provide nursing coverage. He stated he tried to schedule two licensed nurses on days, two licensed nurses on evening shift and one nurse on night shift. During an interview on 5/19/22 at 10:53 a.m., Licensed Nurse P stated usually there were two licensed nurses and four unlicensed staff scheduled for days. Licensed Nurse P stated he worked double shifts and split shifts (Work 6 hours and go home, to return later and work another shift) pretty regularly. He stated he worked a lot of overtime, like 20 hours a week. Licensed Nurse P stated the RNA services were discontinued so that the RNA could work as a CNA. Licensed Nurse P stated the high workload, and the short staffing has a potential for residents to develop contractures without the exercise and stated I worry the hours we put in are not sustainable. If the facility cannot recruit staff I am worried about being able to meet the needs of residents. He stated Things get prioritized and Range of Motion falls off the list of things to do. A review of a facility Policy and Procedure (P&P) titled Restorative Nursing Services, revised July 2017, indicated Residents will receive restorative nursing care as needed to help promote optimal 056483 Page 9 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0725 safety and independence. Level of Harm - Minimal harm or potential for actual harm A review of a facility document titled Restorative Nursing Program, dated 5/28/13, indicated Restorative Nursing Program is a service provided by the facility generally under nursing, to ensure maintenance of patient's optimum level of function.These services must be performed daily.Restorative Nurse's Aide Is responsible for administering the restorative program on a daily basis and will assure that each patient is treated according to the therapist guidelines.Program Structure 1. Frequency of treatment: daily, 7x/wk., QD(every Day). 2. Conducted by RNA on a one-to-one basis . Residents Affected - Some A review of a document titled CENSUS and DIRECT CARE SERVICE HOURSE PER PATIENT DAY(DHPPD), dated 5/1/22 - 5/16/22 indicated out of 15 days: Two-day shifts had only one licensed nurse scheduled when there was supposed to be two licensed nurses. Three evening shifts had only one licensed nurse schedule where there was supposed to be two licensed nurses. Eight evening shifts had only 12 hours of licensed nursing scheduled where there was supposed to be 16 hours. Coverage was provided four times by having licensed nurses work double shifts. A request to review the Policy and Procedure for the staffing matrix for the facility. The Policy and Procedure was not provided before the end of survey. 056483 Page 10 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure the Registered Dietician (RD) provided comprehensive oversight of the dietary services. Failure to ensure comprehensive oversight by the RD might have resulted in: 1. menus were not followed. Refer to F 803; 2. facility did not follow physician prescribed therapeutic diets. Refer to F 808; and 3. the facility did not store and prepare food in accordance with professional standard. Refer to F 812. This failure also had the potential for systematic failures of nutrition service and impaired quality of life for all 35 residents in the facility and had the potential to cause widespread food-borne illness in a vulnerable population with complex medical conditions. Findings: During multiple observations, interviews, and record reviews, from 5/16/22 - 5/20/22, at various times through out the day, nutritional services were provided in a manor that did not meet the 2017 Food Code standards. During an interview with the RD, on 5/20/22, at 10:16 a.m., the RD stated she had been contracted to provide RD services to the facility since 2019. The Rd stated she worked in the facility 1 day a month. The RD stated the facility census was really low, residents were stable, and she did not think the facility was taking admissions. The RD stated she was onsite in April. The RD stated during her monthly visit she would perform a kitchen inspection which included inspection of the physical environment, inspection of food storage, observation of meal preparation, meal portioning and serving. The RD stated results of the inspection were communicated to the facility via a document titled, Sanitation and Food Safety Checklist. The RD stated she also reviewed all new admission residents and participated in weight change meetings. and all new admission assessments. The RD stated a summary of tasks performed was communicated to the facility via documents titled, Consultant Dietitian Report. The RD stated she completed both forms for the month of April. The RD was aware the facility had no documentation to indicate an April visit was completed. During a review of the facility document titled, Sanitation and Food Safety Checklist, dated 3/21/22, the form indicated the RD assessed the equipment which included the ovens and ice machine. The RD indicated equipment was Very Clean - Sparkling! Great Job. The RD indicated all carts and racks were clean and in good repair. The RD indicated soiled rags were stored in labeled covered containers. The RD indicated logs were maintained for the dishwasher and QUAT sanitizer. The RD indicated recipes were followed, spreadsheets were followed, and all food items were received met professional standards. During a review of the facility document titled, Consultant Dietitian Report, dated 3/21/22, the document indicated the RD observed meal service. The document indicated the RD's evaluation of meal service was Great Job. 056483 Page 11 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0801 Level of Harm - Minimal harm or potential for actual harm During an interview with the RD, on 5/20/22, at 10:20 a.m., the RD stated her professional opinion was that the facility's kitchen staff's job performance was exceptional. The RD stated she was, hard pressed to find anything wrong. The RD stated she had not observed staff failing to follow the recipe or cooking methods. The Rd was unaware the facility had many out-of-stock items that required substitution. The RD stated the need for nutritional equivalency of substituted items was not brought to her attention. Residents Affected - Many During an interview with the RD, on 5/20/22, at 10:30 a.m.,, the RD confirmed part of the inspection included food storage. The RD Stated she always looked at food storage. The RD stated she had no concerns in the dry storage area. When asked if she had identified expired food or food without an expiration date in the dry storage the RD stated No. When asked if she had identified items opened and put back into storage the RD stated You tell me. When asked if she had identified a concern that the facility's eggs were not pasteurized, the RD stated she never noticed that. The RD stated she thought she reviewed the kitchen log binder, but she could not recall. The RD stated she identified a concern when the cooks were not documenting food temperatures prior to serving. The RD had not identified a concern with the QUAT log or the dishwashing log. During an interview with the RD, on 5/20/22, at 10:40 a.m.,, the RD stated she had not audited the meal tray cards in comparison to the diet order or to the meal served. The RD stated she had not checked the menu against the food the facility had on hand. The RD stated the facility was supposed to order from the list provided so it should be done. When asked what did she consider her responsibility in regards to oversight of the nutritional services department, the RD stated my effectiveness is only as good as the effectiveness of the dietary manager. The RD refused to elaborate further. During an interview with the administrator, on 5/20/22, at 11:22 a.m., she stated the Dietary manager (DM) and Registered Dietician (RD) managed the dietary department for the facility. The administrator stated she expected the RD to provide services and oversight to maintain the facility in compliance with all the difference regulatory bodies that provided oversight for food services. The administrator stated food safety, sanitization, and resident diets needed to be in compliance. The administrator stated the expectation was for the RD to accurately assess the dietary department for compliance. When asked if failing to identify the ice machine noncompliance for 7 months, or the use of unpasteurized eggs, or the active storage of expired food met the facility expectation; the administrator stated the RD should have identified those concerns. The administrator stated the RD was expected to complete all new admission nutritional assessments. When asked if she thought 3 weeks was an acceptable timeframe to wait for the initial assessment, the administrator stated it should be done right away. The administrator stated 3 weeks was unacceptable. During a review of the facility job description titled, dietician, dated 2003, the document indicated the purpose of the position was to plan, organize, develop and direct the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility. The document indicated the RD was to assure that quality nutritional services were being provided on a daily basis and that the food services department was maintained in a clean, safe, and sanitary manner. The Duties and Responsibilities section indicated the RD would assume the administrative authority, responsibility and accountability of directing the Food Services Department. The section indicated the RD would visit residents periodically to evaluate the quality of meals served, likes and dislikes, mealtimes, bedtime snacks, and food substitutions. The section indicated the RD would review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders. The Staff Development section indicated the RD would develop and participate in the planning, conducting, and scheduling of timely in-service 056483 Page 12 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many training classes that provided instructions on how to do the job, to ensure a well-educated food services department. The section indicated the RD would develop, implement, and maintain an effective orientation program that oriented the new employee to the department, its policies and procedures, and to his/her job duties. The policy further indicated the RD would ensure that food service personnel attended annual/mandatory training programs. The Miscellaneous section indicated the RD would make weekly inspections of all food service functions to assure that quality control measures were continually maintained. 056483 Page 13 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0803 Level of Harm - Minimal harm or potential for actual harm 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure menus were followed when; Residents Affected - Some 1. 3 out of 3 recipes were not followed for the lunch meal served on 5/19/22, 2. All Residents were given 2 slices from a 5 inch personal pizza rather than 2 slices from a twelve inch pizza for the dinner meal served on 5/16/22, 3. The wheat roll was omitted from the lunch meal served on 5/16/22, a substitution was not offered, 4. 1 resident on a pureed diet (Resident 8) received the wrong dessert item for 1 lunch meal served on 5/19/22. These failures resulted in altered nutritional content of the menu and put vulnerable residents at risk for imbalanced nutrition, weight loss and worsening of medical conditions. Findings: 1a. During a review of the facility document titled, Good For Your Health Menus, dated 5/16/22-5/23/22, the menu indicated what was expected for lunch on 5/19/22. The menu indicated Szechuan pork, fried rice, stir fry vegetables, confetti coleslaw, and tapioca pudding would be served. During an observation and concurrent record review, on 5/19/22, at 10:55 a.m., Dietary G used granulated garlic to season the stir fry vegetables. A review of the recipe titled, Stir Fry Vegetables, [undated], indicated powdered garlic would be used. During an interview, on 5/19/22, at 12:15 p.m., With the DM (dietary manager), she confirmed there was a difference between garlic powder and granulated garlic. The DM stated the texture was different. The DM stated the change in ingredients could alter the taste and or the texture of the dish. 1b. During an observation and concurrent record review, on 5/19/22, at 9:25 a.m., Dietary G opened a 3-ring binder that contained recipes for all items listed on the menu. Dietary G started preparing the fried rice. Dietary G poured 2 quarts plus 2 cups of water into a large metal tray that she placed over 2 burners on the range. During an observation and concurrent record review, on 5/19/22, at 9:35 a.m., Dietary G added brown rice to the boiling water. Dietary G stirred the mixture and left the tray on the range. The recipe indicated mix the rice and boiling water then cover tightly and bake at 350 degrees for 45-55 minutes. During an observation and concurrent record review, on 5/19/22, at 10:55 a.m., Dietary G mixed the egg, vegetables, and soy sauce into the brown rice. The recipe indicated the rice would be added to the vegetables and pan fired in oil. 056483 Page 14 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation, on 5/19/22, at 11:45 a.m., Dietary G scooped fried rice into a blender. Dietary G added approximately 4 ounces of the reconstituted chicken broth to the blender. Dietary G blended the mixture for approximately 1 1/2 minutes. During an interview and concurrent record review, on 5/19/22, at 12:15 p.m., with the DM, she reviewed the recipe titled, Fried Rice, [undated]. The recipe indicated for residents with a pureed diet the rice could be pureed with milk as needed. The DM was unable to show documentation that indicated chicken broth was an acceptable liquid to puree the rice with. The DM asked Dietary G how she pureed the rice and Dietary G stated with chicken broth. During an interview and concurrent record review, on 5/19/22, at 12:23 p.m., with the DM and Dietary G, they reviewed the recipe titled, Fried Rice, [undated]. The recipe indicated the rice would be baked and then added to an oiled pan and sauteed with all other ingredients. Dietary G confirmed the rice was boiled, not baked. Dietary G confirmed the other ingredients were cooked and added to the rice in a serving dish, the rice did not get sauteed as per the recipe. Dietary G was asked what product was used when the recipe called for lite soy sauce. Dietary G pulled a large container of dark liquid. The label on the container indicated the liquid was Tamari Soy Sauce. The DM stated the product used was not the same as the lite soy sauce the recipe called for. 1c. During an observation and concurrent record review, on 5/19/22, at 10 a.m., Dietary G reviewed the recipe for Szechuan Pork and stated she was going to make the sauce. Dietary G poured ½ cup plus 1 tablespoon of tamari soy sauce into a measuring cup. A review of the recipe indicated the use of lite soy sauce. Dietary G used a chicken base to make a chicken broth and then used 1 and ½ cups of the broth. A review of the recipe indicated low sodium chicken broth. Dietary G used 1 jar of hoisin sauce, the label indicated it was 7 ounces. A review of the recipe indicated 1 and ½ cups or 12 ounces of hoisin sauce. Dietary G added the other ingredients listed into a pot and put the pot on the range. The Recipe called for 1 and ½ quarts of water which was omitted. The recipe indicated after the pork was fully cooked the excess fat needed to be drained. Dietary G did not drain any fat off the pork. During an observation and concurrent record review, on 5/19/22, at 10:53 a.m., Dietary G added the previously omitted water to the pork and then added the sauce to the pork/water mixture. The pork was left on the range at a full boil in the liquid from 10:53 a.m. until 11:15 a.m. At 11:15 am the pork was moved into the oven. The pork was transferred from the oven to the steam tray at 11:45 a.m. During an observation of [NAME] line, on 5/19/22, at 12:05 p.m., the Szechuan pork tray had liquid that covered 2/3 of the pork. The liquid was thin and ran all over the plate when the scoop of pork was plated. During an interview and concurrent record review, on 5/19/22, at 12:23 p.m., with the DM and Dietary G, they reviewed the recipe titled, Szechuan Pork, [undated]. The recipe indicated the sauce would be made with lite soy sauce. Dietary G was asked what product was used when the recipe called for lite soy sauce. Dietary G pulled a large container of dark liquid. The label on the container indicated the liquid was Tamari Soy Sauce. The DM stated the product used was not the same as the lite soy sauce the recipe called for. Dietary G was asked what product was used when the recipe called for low sodium chicken broth. Dietary G pulled a tub of Chicken Base from the refrigerator and stated the base was mixed with water to make the broth. The DM reviewed the tub and stated the product used was not the same as the low sodium chicken broth listed on the recipe. Dietary G was asked if they found Hoisin sauce as indicated by the recipe and Dietary G provided 1 empty 14 tablespoon jar of hoisin 056483 Page 15 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sauce. Dietary G confirmed only 14 tablespoons were used instead of the 24 tablespoons the recipe called for. Dietary G stated that was all the facility had. During an interview and concurrent record review, on 5/19/22, at 12:30 p.m., with the DM and Dietary G, they stated the Registered Dietician (RD) was not made aware or consulted for any of the changes to the recipe or cooking technique. A review of the document titled, Substitution Log, dated [DATE], showed no indication the changes had been documented. The DM reviewed the log and confirmed none of the changes that had been made throughout the week were documented for the RD to review. During an interview on 5/19/22, at 12:45 p.m., with the DM, she stated the changes made to the recipe would change the nutritional composition of the meal. The DM stated the meal had a lot more sodium. During a review of the nutritional labels for the ingredients used and the ingredients listed in the recipes a comparison of the sodium content was reviewed. The lunch meal on 5/19/22 would have had 308 milligrams (mgs) of sodium (a mineral that is important for maintaining normal fluid balance in the body, diets higher in sodium are associated with an increased risk of developing high blood pressure, which is a major cause of stroke and heart disease) per regular serving if it was prepared as indicated in the recipes. The lunch meal on 5/19/22 had 442 mgs of sodium per regular serving. The lunch meal had 133 mg, equal to 43 percent more sodium than intended. During a review of a recipe titled, The Best Szechuan Sauce, dated 5/25/2019, indicated Szechuan Sauce was a thick and bold Chinese condiment that had savory heat and a tangy bit of sweetness. The recipe indicated the sauce was highly viscose. The recipe indicated the thickness of the sauce was similar to a very thick BBQ sauce. 2. During an observation and interview on 5/17/22 at 8:56 a.m., Resident 4 stated for dinner on 5/16/22, they served two small pieces of pizza smaller that his computer mouse. He stated it was cold and tasted terrible. Resident 4 stated he asked for a substitution of a grilled cheese sandwich, and they brought him another slice of cold pizza. He stated the green salad was put through a blender and was flaky in texture. He stated it was very unappetizing. Resident 4 state he and his roommate wanted to order a takeout pizza because they could not eat their dinner. During an interview with the DM, on 5/17/22, at 11:13 a.m., she stated the facility's food supplier was not providing the food ordered. The DM stated there was many items that were out of stock. The DM stated some of the items would be substituted for a different item the supplier had. The DM stated sometimes there was just a lack of food products. During an interview and concurrent record review, with the DM and Dietary G, on 5/17/22, at 11:23 a.m., Dietary G stated the facility received 5-inch personal size cheese pizzas form the supplier. The DM reviewed the Spring Cycle Menu document titled, Cooks Spreadsheet, [undated], and stated the menu indicated a regular serving would be 2 slices from a 12-inch combination pizza that had been cut into 16 slices. The DM stated the RD had not been consulted to determine nutritional equivalency. Dietary G stated she thought they had about 15 pizzas for 35 residents. Dietary G confirmed they cut the personal pizza into slices and gave each resident 2 pieces. 3. During an observation, on 5/16/22, 12:25 p.m., in Resident 2's room, Resident 2's lunch tray was served. There was no wheat roll on her tray. The meal ticket card on Resident 2's tray indicated the meal would include a wheat roll. 056483 Page 16 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation, on 5/16/22, 12:26 p.m., in Resident 6's room, Resident 6's lunch tray was served. There was no wheat roll on her tray. The meal ticket card on Resident 6's tray indicated the meal would include a wheat roll. During an interview with Unlicensed Staff K (UN K), on 5/16/22, at 12:40 p.m., UN K stated none of the trays had wheat rolls on them. During an interview and concurrent record review, on 5/17/22, at 11:40 a.m., with the DM, she reviewed the Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Monday. The menu indicated the lunch meal was roast turkey with [NAME] sauce, parsley and herb penne pasta, green beans with garlic, a wheat roll, and an apple crisp. The DM stated she did not know there was a missing item from the lunch meal. The DM stated there was no communication to herself or the Registered Dietician (RD) from staff that indicated a missing item from the lunch meal. During an interview with Dietary H, on 5/17/22, at 11:50 a.m., she stated she remembered making the rolls. Dietary H stated she did not plate the lunch meal on 5/16/22. Dietary H stated the rolls were prepared but not included on the trays, they were missed. 4. During an interview and concurrent record review, on 5/19/22, at 12:25 p.m., with the DM, she reviewed the Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Thursday. The spreadsheet indicated residents on the pureed therapeutic diet would get P-cherry instead of tapioca pudding. The DM stated she did not know what P-cherry was. Dietary J stated she pureed the tapioca pudding for the lunch meal. During a review of the facility policy and procedure titled, Food Preparation, dated 2018, the policy indicated the facility will use approved recipes, standardized to meet the resident census. The policy indicated recipes were specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 056483 Page 17 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0808 Level of Harm - Minimal harm or potential for actual harm 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 observation, interview, and record review, the facility failed to follow the physician prescribed therapeutic diets when: Residents Affected - Some 1. Mechanical Soft (MS) texture was not followed during the 5/19/22 lunch meal, which increased the risk for choking for residents with chewing or swallowing difficulty; 2. High protein diets were not followed, which had the potential for worsening nutritional status of residents that needed protein dense meals. Failure to follow physician ordered diets had the potential to compromise the medical status for all 23 residents with a therapeutic diet. Findings: 1. During an observation, on 5/19/22, at 12:10 p.m., in the kitchen, Dietary G removed 8-10 scoopfuls of pork and put them into a food processor. Dietary G pulsed the food processor 4 short pulses and 2 long pulses. During a concurrent interview and record review, on 5/19/22, at 12:25 p.m., with the DM and Dietary G, Dietary G stated the pork in the food processor was used for residents on a mechanical soft diet. Dietary G stated the small, chopped up pork pieces were appropriate for residents on a mechanical soft therapeutic diet. The DM stated she agreed with Dietary G. The DM reviewed the Szechuan Pork recipe, the special diets section indicated, Dysphagia/ Mechanical Soft: grind pork and make recipe. The DM reviewed a document titled, Spring Cycle Menus Cooks Spreadsheet, dated Week 3 Thursday, the spreadsheet indicated mechanical soft and dysphagia mechanical were two different therapeutic diet options. The spreadsheet indicated, make recipe but grind pork for both options. Dietary G stated she did not use ground pork to make any lunch items. 2. During an interview with the DM, on 5/17/22, at 12:10 p.m., she stated she was not sure if the supplement shakes in stock were considered high protein. During a review of the resident meal tray cards, dated 5/16/22, 6 cards indicated the meal included a high protein shake. During an interview, on 5/17/22, 4:35 p.m., with Licensed Nurse W (LN W), she stated Resident 13 was given a high protein shake every meal. LN W stated the shake was served in a glass with a lid. LN W stated the shake was a doctor's order on Resident 13's Medication Administration Record (MAR). LN W stated she documented the percentage consumed on Resident 13's MAR. When asked how the nurse knew the supplement was high protein, LN W stated she assumed it was, since it was listed on the card as a high protein shake. During an interview with the Registered Dietician (RD), on 5/20/22, at 10:30 a.m., she stated she heard the survey team was asking about the high protein shake supplements. The RD did not answer when 056483 Page 18 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked if the shakes the facility had in stock were considered high protein. The RD stated she audited the resident's electronic medical records on 5/19/22. The RD stated she changed all the supplement orders from high protein shake to house supplement. When asked what were the nutritional parameters for house supplements, the RD stated it did not matter. The RD stated the facility could use any brand supplement, whatever was available at the time. The RD stated she could write or change any and all diet orders, including supplement orders, per her scope of practice. During a review of the facility policy and procedure titled, Purchasing Food And Supplies, dated 2018, the policy indicated supplies shall be appropriate to meet the requirements of the menu and therapeutic diets ordered. 056483 Page 19 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: Residents Affected - Many 1. eggs were purchased for resident consumption that were not pasteurized, 2. food was stored past the facility's use by date, 3. food was stored in open packaging, 4. fruits and vegetables stored for use had mold spots, had turned brown, and had gotten soft and squishy, 5. food containers were removed from their external packaging and stored without documentation to show the products expiration date, 6. prepared food was stored and ready for use past the facility's policy, 7. food preparation areas were not cleaned or sanitized between uses, 8. staff did not perform hand hygiene after removing their gloves, 9. the solution used to sanitize kitchen surfaces was not at an acceptable concentration per the manufacturer's guidelines 79 times out of 79 opportunities, 10. the internal components of the ice machine were not drained, cleaned, and sanitized as needed or according to the manufacturer's specifications, 11. the dishwashing machines manufacturer's instructions to ensure clean sanitized dishes were not followed, 12. Fans, vents, drains, oven knobs, and the stationary can opener were visibly soiled with large amounts of build-up and debris on them. These failures had the potential to result in a food-borne illness outbreak amongst a population of vulnerable residents with complex medical conditions. Findings: 1. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:11 p.m., in the refrigerator, there were 2 full cases of eggs and one open tray of eggs. There was no indication on the open eggs that the product had been pasteurized. Dietary H pulled out 1 case of eggs and read the labels. Dietary H was unable to find any indication that the eggs had been pasteurized. Dietary H stated they cooked with eggs, as well as made eggs in many different ways almost every breakfast. During a concurrent observation and interview, on 5/17/22, at 10:57 a.m., with DM, in the kitchen, the DM inspected an egg. The DM stated usually pasteurized eggs had a marking on the shell. The DM 056483 Page 20 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the eggs in the refrigerator did not have any markings on them. The DM inspected the cardboard box the eggs were delivered in. The DM was unable to locate any label to indicate the eggs were pasteurized. The DM stated if the eggs were not pasteurized, they would not suitable for use in the facility. 2. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, on the back shelf was a box of powdered drink mix and a pouch of powdered instant pudding mix. The powdered drink mix had a delivery date of 1/2021. The pouch of powdered instant pudding mix had a delivery date of 7/2/21. Dietary H stated the facility followed a universal food storage guideline and pointed to a paper pinned to the wall. Dietary H looked at the powders then reviewed the guideline and stated the pudding mix should be stored for only 6 months. During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, she stated she was aware there was expired pudding and pink lemonade mix in the storage area. The DM looked at an open case of canned meat and stated the product had gone past the facility's universal storage guideline date. 3. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, there was an open box of carrot cake mix. Dietary H opened the box and stated the plastic bag was left open. Dietary H stated open food items should be tied or in some way closed for storage. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the freezer, there was a cardboard box labeled beef patties. The cardboard box had the tape removed which indicated it had been previously opened. Inside the cardboard box was a plastic bag filled with frozen beef patties. The bag had an opening than spanned the width of the bag. Dietary H stated the plastic should have been tied or in some way sealed. Dietary H stated the bag could be tied or the patties could be transferred to a resalable plastic storage bag During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, an open box of carrot cake mix was stored on the back shelf. Inside the box was an open plastic bag of carrot cake mix. The DM looked into the box and stated the plastic bag should be tied or sealed. The DM stated storing the mix in an open bag increased the risk for contamination. During a concurrent observation and interview, on 5/17/22, at 10:56 a.m., with DM, in the kitchen, she opened the freezer. In the freezer there was a cardboard box labeled beef patties. The cardboard box had the tape removed which indicated it had been previously opened. Inside the cardboard box was a plastic bag filled with frozen beef patties. The bag had an opening than spanned the width of the bag. The DM stated the patties should not be stored with the packaging open. The DM stated the expectation was to close or seal all items in storage. During a concurrent observation and interview, on 5/19/22, at 8:50 a.m., with DM, in the kitchen, she opened the freezer. Inside the freezer was an open cardboard box that contained an open plastic bag full of bacon. The DM stated the plastic bag should be tied or sealed prior to putting the box back into the freezer. The DM stated the bacon was at risk for contamination or freezer burn (a condition that occurs when frozen food has been damaged by dehydration and oxidation due to air reaching the food). The DM took plastic storage bags that had a resalable opening from a drawer and asked staff to portion the bacon into the bags and store them sealed. 4. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, 056483 Page 21 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many there were three bunches of bananas on a shelf. The bananas were black on approximately 80% of their peel. Dietary H stated, we have what we have and explained if they threw out the bananas, they wouldn't have any fresh fruit. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:11 p.m., in the refrigerator, there was a clear plastic bin that contained carrots tomatoes and cucumbers. The tomatoes had multiple small black fuzzy spots on their skin. Dietary H looked at the bin and stated the tomatoes needed to be thrown out. Dietary H pulled the bin out of the refrigerator and placed it on a countertop. Dietary H removed the tomatoes from the bin. During the adjustment 1 cucumber had a wrinkled texture at both ends that spanned approximately 2 inches inwards. Dietary H touched the cucumber and it squished. Upon further inspection almost every cucumber had some length of wrinkled squishy part. Dietary H stated they must have gone bad. Dietary H called out to Dietary E and asked E to sort through the vegetables and remove the bad ones. During a concurrent observation and interview, on 5/17/22, at 11 a.m., with DM, in the kitchen, she stated vegetables should not be stored or used if they had signs or mold or had gone bad in any way. 5. During an initial kitchen tour with Dietary H, on 5/16/22, at 12 p.m., in the dry storage room, there were multiple large cans of sauces, boxes of fruit juice concentrates, and cartons of thickened water all with no expiration date labeled on the packaging. Dietary H looked for an indication of the expiration date on each item. Dietary H stated she thought the date was printed on the cardboard box the items were delivered in. Dietary H pulled out a cardboard box with a label that indicated 1 case of fruit juice concentrate. On the cardboard there was a stamped expiration date of 3/2024. When asked how staff would know if a food item was not expired if it was not stored in the outer cardboard Dietary H stated they referred to the universal storage guideline. When asked what would happen if the product delivered expired sooner than the storage time indicated on the universal guideline Dietary H stated she did not know. During a concurrent observation and interview, on 5/17/22, at 10:50 a.m., with DM, in the dry storage room, she looked at the [brand] cans and cartons for the manufacturer's expiration date. The DM stated she could not find and expiration date. The DM stated the date was stamped onto the cardboard boxes the products were delivered in. The DM confirmed it was the facility's practice to remove the products from the outer cardboard packaging. The DM stated she knew the products were not expired because they used a first in last out stocking plan and did not stockpile products. The DM stated the facility used a universal storage guideline. When asked what would happen if the supplier provided a product that was due to expire sooner than the universal guide indicated the item could be stored, the DM stated the product would be expired. The DM stated she would have no way of knowing the product was expired. 6. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:10 p.m., in the refrigerator, there was a tray of sandwiches dated 5/12/22. Dietary H stated the sandwiches were made in the kitchen for resident snacks and per resident request. Dietary H stated the facility policy indicated sandwiches could be stored for 72 hours. Dietary H looked at the date on the sandwiches and stated they should be thrown out. Dietary H stated she did not know whether any residents had received sandwiches outside of the 72-hour window. During a concurrent observation and interview, on 5/17/22, at 10:56 a.m., with DM, in the kitchen, she stated she thought sandwiches prepared by staff would not be stored longer than 1 day. The DM 056483 Page 22 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the staff would refer to the universal storage guideline. The DM stated she expected staff to throw out any food items not used within acceptable storage time. 7. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., in the room used to wash dishes, Dietary H was asked how the staff cleaned and disinfected the kitchen. Dietary H removed a spray bottle from a closet and stated she sprayed the product on a surface and then wiped it dry with a towel. During a review of the spray bottle label, the how to use section, indicated the product was used to sanitize hard, non-porous food contact surfaces. The label indicated surfaces must be pre-cleaned with the same product prior to sanitizing. The label indicated no rinse was required prior to sanitizing. The label indicated to sanitize, spray the product 6-8 inches away from the hard, non-porous surface. The label indicated the surface needed to remain wet for not less than 1 minute. The label indicated the surface should be allowed to air dry. During a concurrent observation and interview, on 5/17/22, at 11:07 a.m., with DM, in the dishwashing room, the DM stated red and green buckets were used to clean and sanitize the kitchen. The DM stated the green bucket was filled with soap and water and the red bucket was a QUAT (Ammonium quaternary compounds are potent disinfectant chemicals that can often effectively kill germs on surfaces that have not been fully washed and rinsed) sanitizer from an auto pump machine. The DM was unable to locate where the filled, in use buckets were located. The DM was not aware of any cleaning and sanitizing sprays used in the kitchen. During an observation, on 5/19/22, at 9:45 a.m., in the kitchen, dietary G added approximately 4 ounces of soap to a green 6 quart plastic bucket. Dietary G filled the bucket with water. Dietary G used a white towel and the soap solution from the green bucket to wipe the counter workspace that was used to cut carrots and onions for the fried rice. Dietary G put the used towel into the green bucket and then walked away. No sanitizing solution was used on the workspace. During an observation, on 5/19/22, at 9:50 a.m., in the kitchen, Dietary V was chopping raw pork cubes into smaller pieces. Dietary V finished chopping the pork and placed the large metal tray of pork onto 2 burners on the range. Dietary G walked a crossed the kitchen and showed Dietary V the green bucket. Dietary V used the towel from the green bucket and wiped down the workspace. Dietary V put the towel back into the green bucket and walked away. No sanitizing solution was used on the workspace. During a concurrent observation and interview, on 5/19/22, at 9:50 a.m., with DM, in the kitchen, the DM stated towels should be used once and then put aside to be laundered. The DM stated the staff should be cleaning and then using QUAT sanitizer on all workspaces between tasks. The DM removed the rag from the bucket. The DM was unable to locate a receptacle for used towels. The DM asked Dietary G what was in the green bucket and confirmed it was water and soap. The DM was unable to locate where any QUAT solution had been prepared and used after each task. The DM had no answer when asked how the staff had been cleaning and sanitizing all day long if the buckets were not in use. During an observation, on 5/19/22, at 11 a.m., in the kitchen, Dietary J finished pouring drinks for lunch meal. Dietary J switched tasks to portioning and serving tapioca pudding. Dietary J did not wash or sanitize the workstation prior to switching tasks. During an observation and concurrent record review, on 5/19/22, at 11:30 a.m., Dietary E chopped 056483 Page 23 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm lettuce, then tomatoes, then carrots, without cleaning and sanitizing the workstation. Dietary E used the same knife for all three tasks without cleaning and sanitizing to prevent cross contamination. 8. During an observation, on 5/19/22, at 9:31 a.m., Dietary H removed a pair of gloves and put on a new pair. No hand hygiene observed before putting on the clean gloves. Residents Affected - Many 9. During a concurrent interview and record review, on 5/17/22, at 11:20 a.m., with DM, the log binder was reviewed. The facility document titled, Quaternary Ammonium Log, dated 5/22, indicated the expectation was for staff to test the concentration and document it in the log 5 times a day. The log indicated proper concentration would be between 150-200 ppm. The log indicated the concentration was 700 ppm for 79 tests out of 79 opportunities. The DM stated she did not know the QUAT had a known concentration of 700. The DM did not know what test kit the staff was testing with. 10. During an interview with MS (maintenance supervisor), on 5/17/22, 3 p.m., he stated he cleaned and wiped down the outside of the ice machine daily. The MS stated that had a contracted company that serviced the ice machine every 6 months. The MS provided documentation that showed daily external cleaning. The MS provided documentation that indicated a company had completed quarterly impatience on 7/29/2021. During a review of the ice machine's manual chapter 4 titled, Maintenance, [undated], indicated the machine required a Remedial Cleaning Procedure to be completed at least monthly or as indicated by the electronic menu indicator. During an interview with the Maintenance Supervisor (MS), on 5/19/22, at 12:05 p.m., he stated the menu on the ice machine was never set-up. MS confirmed the ice machine could provide monthly alert reminders to clean the interior components of the machine and complete monthly descaling. MS stated at the time on instillation he was not aware of the menu and its functions. MS confirmed the manufacturer's instructions included a cleaning and descaling at least monthly, if not sooner based on ice consumption. MS stated he had placed a call to a repair company and that a technician would be out within the hour to perform a cleaning and descaling procedure. MS stated the technician would also set up the menu on the ice machine. During an interview on 5/19/22, at 4:20 p.m., with the ice machine technician, he stated the ice machine had shown signs of buildup. The technician confirmed the menu had not been activated when the machine was installed. 11. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., in the room used to wash dishes, Dietary V was washing dishes. The gauge on the dishwasher indicated a temperature of 110 degrees during both the wash and rinse cycles. Dietary H stated the machine was a high temperature dishwasher. The sink on the dirty side of the dishwasher had a large garbage disposal attached to the drain. Dietary V stated the garbage disposal was not working. The wall that separated the dishwashing room and the kitchen had a 3 compartment sink. The wall had plastic wrapped around each side of it. Dietary H stated the sink was not in use. Dietary H stated there was a leak and the wall had been partially demolished and needed to be replaced. During a concurrent observation and interview, on 5/17/22, at 11:10 a.m., with DM, in the dishwashing room, the DM stated the dishwasher was a low temperature machine that used chemicals to sanitize. The DM stated the water needed to reach 120 degrees during the wash cycle. The DM stated the water 056483 Page 24 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many needed to reach 120 degrees during the rinse cycle. The DM stated the sanitizer needed to have a concentration of 50 or more to be effective. The DM stated the expectation was that staff tested the sanitizer and recorded the concentration in the log binder. During a concurrent observation and interview, on 5/17/22, at 11:13 a.m., with DM, in the dishwashing room, a load of dishes was put into the dishwasher. The gauge at the bottom of the machine reached 118 degrees during the wash cycle. The gauge at the bottom of the machine reached 118 degrees during the rinse cycle. The DM stated the machine needed to warm up. The DM took a small piece of paper out of a plastic tube and dipped it into the water after the cycle was complete. The paper changed to different shades of purple to indicate the sanitizer concentration. The plastic tube had a label that indicated the paper expired 6/1/21. The DM looked at a second tube and stated that one expired 4/1/22. The DM stated she would need to call the MS and get papers that were not expired. The DM stated the expired papers might not give an accurate concentration level. During a concurrent interview and record review, on 5/17/22, at 11:20 a.m., with DM, the log binder was reviewed. The facility document titled, Dish Machine Temperature Log, dated 5/22, indicated the expectation was the wash cycle temperature, the rinse cycle temperature and the sanitizer concentration were documented 3 times a day. The log indicated the wash cycle was 120 degrees for 46 cycles out of 46 opportunities. The log indicated the rinse cycle was 125 degrees for 46 cycles out of 46 opportunities. The log indicated the sanitizer concentration had been recorded 0 out of 46 opportunities. The DM stated she did not know the log was incomplete. During an interview with MS, on 5/17/22, 11:35 a.m., he stated the facility contracted a company to maintain the dishwasher. The MS stated the company services the machine monthly. The MS stated the machine should be at temperature without warming up because it was piped directly from the hot water tank. The MS stated he would call the company to assess the temperature and provide more strips. During an interview with the dishwasher technician, on 5/17/22, 12:05 p.m., he stated the dishwasher was set to wash at 120 degrees, rinse at 122 degrees and have a 90 ppm concentration of sanitizer. The technician stated if the temperature was not reached the dishes would need to be rewashed. The technician stated the sanitizer could get highly concentrated if there was something blocking the water intake. The technician stated a common blockage was seen when a plastic lid to a cup was accidentally left on a dish and then blocked the water intake. The technician confirmed the dishwasher was not reaching temperature during both the wash and rinse cycles. During an interview with the administrator, on 5/17/22, at 12:37 p.m., she stated she was aware there was an issue with the dishwashing machine. The administrator stated the technician inspected the machine and determined the gauge was broken. The administrator stated a thermometer was used to verify the water was above 138 degrees for both the wash and rinse cycles. The administrator could not determine when the gauge was broken or how the staff was able to get exactly 120 and 125 degrees on a gauge that was stuck and would not go above 118 degrees. 12. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., the ovens and range were approximately 90% covered in black sticky buildup. On the front of the oven there were knobs to control burner temperatures. In the open space around each knob there was black sticky buildup, crumbs of various colors and sized and fluffy dust material filling approximately 80% of each space. When asked who cleaned the ovens and range, Dietary H stated she did not know. During an initial kitchen tour with Dietary H, on 5/16/22, at 12:15 p.m., the room used to wash 056483 Page 25 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dishes had debris and buildup on almost every surface. The two ceiling fans and one exhaust vent were caked in gray fuzzy dust that crumbed and fell to the surface below with gentle touch. Dietary H observed the dust and stated the maintenance department cleaned the equipment. The dishwasher drain had large particles of food and bits of wrappers covering approximately 50% of the drain screen. The metal back splash, and metal tables on the dirty and clean sides of the dishwasher had splattered off white spots and food debris in the corners. In the center of the room was a metal 3-tiered cart. Each tier had metal rods a crossed the width of the cart approximately 3 inches apart. The cart had rust covering almost every lateral surface and some vertical surfaces. Dietary H grabbed the cart and stated it was the rack used to air dry the plastic covers that go over resident meal plates. Dietary H confirmed the rusty cart was in use in its current state. When asked if the rust ever transferred to the plastic Dietary H stated they had to be careful because when the rust got wet it would drip onto the covers below. During a concurrent observation and interview, on 5/17/22, at 11:05 a.m., with DM, in the dishwashing room, the DM stated the Maintenance Supervisor (MS) and his department were responsible for cleaning the equipment and both rooms. During an interview with MS, on 5/17/22, 11:35 a.m., he stated the facility was out of dishwasher sanitizer test strips. The MS confirmed he was responsible for cleaning and maintaining the kitchen and dish washing rooms. The MS stated the vents, fans and all aspects of the rooms were cleaned weekly. The MS was unable to provide documentation to show a log or cleaning schedule. The MS could not explain how the level of buildup on the vents, fans, and oven had accumulated in 1 week. According to a review of the USDA Food Code, 2017, the standard of practice was to ensure dietetic services areas and equipment were clean to site and touch. During a review of the facility policy and procedure titled, Sanitation, dated 2018, the policy indicated the facility would have a cleaning schedule in which each cleaning task is assigned to an employee by name or job title. The policy indicated all counters shelves and equipment would be kept clean, free from corrosions and maintained and in good repair. The policy indicated ice that was used in connection with food.or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. The policy indicated after each use chopping boards would be thoroughly cleaned and sanitized. The policy indicated no use of cleaning products or sanitizer in the food preparation or food storage areas that in any way that could result in contamination of exposed food items. That included spraying or pouring cleaning products near food items, during preparation, or while cooking. During a review of the facility policy and procedure titled, Quaternary Ammonium Log Policy, dated 2018, indicated the concentration of the ammonium in the quaternary sanitizer would be tested to ensure the effectiveness of the solution. The policy indicated the concentration would be tested at least every shift or when the solution was cloudy. The policy indicated the solution would be replaced when the reading was below 200 ppm. The policy indicated a high concentration may be potentially hazardous and may be a chemical contaminate of food. 056483 Page 26 of 27 056483 05/20/2022 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0867 Level of Harm - Minimal harm or potential for actual harm Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to ensure an active and engaged Quality Assurance and Performance Improvement committee. Residents Affected - Some This failure had the potential to not proactively identify resident care issues and develop a sustainable plan to address the concerns. Findings: During an interview and record review, with the Administrator, on 5/20/22 at 12:31 p.m., she stated she had started as the Administrator in April 2022, and had met once with the Quality Assurance Performance Assurance Committee. She could not provide a Quality Assurance Performance Improvement Plan, approved by the QAPI Committee or Governing board for 2022. She stated she had prioritized to work on Dietary Remodeling Issues and Staffing. The Administrator stated she had not fully developed the QAPI process at this time. A review of the QAPI minutes indicated the committee met in April, but had not fully developed any Performance Improvement Projects to address Falls Prevention, Staffing shortages, Suspension of the Restorative Nursing Assistant program, Pharmacy Recommendations, or Dietary Issues. A review of the QAPI binder indicated a QAPI Committee had met in April 2022. The minutes of the meeting were reviewed and did not indicate a facility specific plan, identify any resident care issues or have any QAPI Policies and procedures. 056483 Page 27 of 27