Health inspection·December 6, 2023

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, interviews, and record reviews, the facility failed to employ a Certified Dietary Manager with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, when there was no designated full time Director of Food and Nutrition Services onsite, as required, when the facility's Registered Dietitian was not employed on a full-time basis. This failure had the potential to result in food borne illnesses when no oversight was provided to the dietary staff during food preparation and could affect the health and safety of all residents of the facility. Findings: During a concurrent observation and interview on 9/14/23, at 2:15 p.m., with Dietary Staff A, the dietary manager was not in the facility. Dietary Staff A stated Dietary Staff B was the dietary manager, and if there were issues in the kitchen, he would contact her by phone. During an interview on 9/14/23, at 2:40 p.m., with CNA C (Certified Nursing Assistant C), she stated she had not seen this dietary manager (Dietary Staff B) in the building. CNA C stated, This is what the facility does, put out names from their other facility and make it seem like they actually work here. During an interview on 9/14/23, at 3:25 p.m., with Dietary Staff B, she stated she was a full-time employee of another facility but she was not a full-time employee at this facility. Dietary Staff B stated the last time she was at this facility was from 7/14/23-7/15/23. During an interview on 9/14/23, at 3:35 p.m., with the facility's RD (Registered Dietitian) consultant. She stated the facility's former dietary manager left the second week of July 2023. The RD consultant stated she was not a full-time dietitian of this facility. A review of a resident's (Resident 1's) MDS (Minimum Data Set- is part of the federally-mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) Section C (Cognitive Patterns), dated 7/21/23, indicated Resident 1's BIMS (Brief Interview for Mental Status) score was 15 (0-7= suggests severe cognitive impairment, 8-12, suggests moderate cognitive impairment, 13-15= suggests cognitively intact, no impairment). During an interview on 12/1/23, at 10:28 a.m., with Resident 1, he stated he had concerns about the food because it did not look appetizing and was not served hot. Resident 1 stated he would end up (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056483 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)