Health inspection·September 8, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, and record review, the facility failed to ensure staffing requirements were met when the facility did not employ a registered nurse (RN) to serve as the Director of Nursing (DON) on a full-time (40 hours per week) basis. This failure resulted in a lack of administrative oversight and supervision and has the potential to affect the quality of care delivered to all residents by nursing staff. Findings: During a record review on 9/5/23, of the facility's staffing records for the month of August 2023, it was noted the DON was not present in the facility on Thursdays and Fridays. During an interview on 9/6/23 at 3:22 p.m. with DON, DON stated, she works three days a week, Monday, Tuesday and Wednesday, eight hours a day. This has been her schedule for the last two years. DON stated she understood the DON position should be full-time, but she can only work part-time. During an interview on 9/7/23 at 11:00 a.m. with Administrator (ADM), ADM confirmed the DON doesn't work full-time at the facility. ADM stated the DON position should be full-time. During a record review of the Facility Assessment Tool (FAT), dated May 2023-May 2024, the FAT indicated, Staffing Plan .DON: 1 DON RN full-time Days. Page 1 of 21 555645 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0760 Ensure that residents are free from significant medication errors. 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 one resident (Resident 1) of 13 sampled residents was free of a significant medication error when she received insulin glargine (a long-acting insulin, medication to lower blood sugar level) 10 times (doses) past the expiration date. Residents Affected - Few This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident. Findings: During a concurrent observation and interview on [DATE] at 11:03 a.m. with Licensed Nurse 1 (LN 1), an inspection of Medication Cart 2 identified one opened insulin glargine 100 units/milliliter (u/ml, a unit of measurement) vial, expired on [DATE], for Resident 1. LN 1 confirmed the finding and stated it should have been removed from the cart and not available for use. A review of Resident 1's medical record indicated a physicians' order, dated [DATE], for insulin glargine 100 u/ml, give 10 units sub-q (under the skin) once daily at bedtime. During a concurrent interview and record review on [DATE] at 11:10 a.m. with LN 1, Resident 1's Medication Administration Record (MAR), dated [DATE] and [DATE] was reviewed. The MARs indicated Resident 1 was administered expired insulin glargine on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. LN 1 stated insulin glargine expired 28 days after first use and Resident 1 was administered a total of 10 doses of expired insulin. He confirmed it was important to check expiration dates on medications before administering them to a resident. During an interview on [DATE] at 1:50 p.m. with LN 2, LN 2 stated she would check the expiration dates on medications before administering them and, The ones I worry about the most is insulin . Somehow those get missed. During an interview on [DATE] at 2:58 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration dates of medication before administering them to a resident, especially insulin. DON stated after expiring, insulin was potentially no longer effective. During an interview on [DATE] at 9:05 a.m. with Consultant Pharmacist (CP), CP confirmed insulin glargine was stable for 28 days once opened and beyond that, it should not have been used. He stated, My concern [with expired Brand Name insulin glargine] would be erratic blood sugar levels .Possibly contamination from being opened too long. During a review of the product labeling from the manufacturer of insulin glargine, revised [DATE], the labeling indicated, Do not use [Brand Name insulin glargine] . 28 days after you first use it. According to Consumermedsafety.org (a nationally recognized medication safety organization), it indicated, 6 Important Storage tips for all insulin .Never use insulin if expired .You must throw away after 28 days since out of the fridge. (https://www.consumermedsafety.org/insulin-safety-center/insulin-basics/storage-of-insulin; accessed [DATE]) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, 555645 Page 2 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dated [DATE], the P&P indicated, Policy Interpretation and Implementation .The expiration/beyond use date on the medication label must be checked prior to administering . During a review of the facility's P&P titled, Storage of Medications, dated [DATE], the P&P indicated, Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 555645 Page 3 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Some -Opened multi-dose inhalers and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date; and -Expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date. Findings: During a concurrent observation and interview on 9/5/23 at 10:13 a.m. with Licensed Nurse 2 (LN 2), an inspection of Medication Cart 1 (Med Cart 1) identified one Brand Name (an inhaler to treat asthma) 200 microgram/25 microgram (mcg, a unit of measurement) inhaler and one Brand Name Inhub (an inhaler to treat asthma) 500 mcg/50 mcg inhaler, both opened and unlabeled with an open date. LN 2 reviewed the manufacturer's specifications on the outside of the Brand Name and Brand Name Inhub inhalers. LN 2 stated the manufacturer's specifications indicated both had shorter expirations after first use and should have been labeled with an open date. During a concurrent observation and interview on 9/5/23 at 11:03 a.m. with LN 1, an inspection of Med Cart 2 identified one vial Brand Name test strips (used to test blood sugar levels) opened and unlabeled with an open date. LN 1 confirmed the finding and reviewed the manufacturer's specifications on the side of the vial. LN 1 confirmed the manufacturer indicated the test strips expired three months once opened and should have been marked with an open date. Inspection of the med cart also identified one opened insulin glargine (a long-acting insulin to treat diabetes) 100 units/milliliter vial, expired 8/25/23. LN 1 confirmed it should have been removed and not available for use. During an interview on 9/5/23 at 2:58 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to check the expiration date of a medication before administering it to a resident. She stated the med carts were inspected for expired drugs once a month as part of the facility's quality assurance program. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated December 2012, the P&P indicated, Policy Interpretation and Implementation .When opening a multi-dose container, the date opened shall be recorded on the container. During a review of the facility's P&P titled, Storage of Medications, dated April 2007, the P&P indicated, Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 555645 Page 4 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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: 1. The Dietary Manager (DM) met the state's education qualification requirements, as required per federal regulation, to be the DM to carry out the functions of the food and nutrition services; and, 2. The Registered Dietitian (RD) provided frequently scheduled consultation to the DM to include overseeing food safety and sanitation, food preparation, meal service and food storage. These failures resulted in lapses in the delivery of food and nutrition services associated with meal distribution, safe food handling, sanitation, and insufficient oversight of food service operations for a census of 29 residents who received meals from the facility kitchen. Findings: During the annual recertification survey from 9/5/23 to 9/8/2023, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - The menu/recipes were not followed and the portion size of food items were not served correctly, and 2. Safe food handling and sanitation: a. The ice machines in the kitchen and nourishment room (located in nursing station) were not clean; b. Improper labeling and dating of food items in the dry storage, walk-in refrigerator, and dry storage room; c. Improper storage of opened food packages in the dry storage, walk-in refrigerator, and dry storage room; d. Expired food items were found in the dry storage room and walk-in refrigerator; e. Improper storage of trays of prepared food were uncovered, unlabeled, and undated in the walk-in and reach-in refrigerators; f. The [NAME] was unable to verbalize the proper cool down process of food and did not practice safe food handling while preparing food; g. Clean and ready-to-use food serving utensils stored in two drawers that were dirty and not well maintained; h. The reach-in freezer had ice buildup and the gasket was torn; i. The juice dispenser was not cleaned per the manufacturer's instruction, and 555645 Page 5 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0801 j. One dietary aide did not appropriately record the sanitizer concentrations in the log. Level of Harm - Minimal harm or potential for actual harm During an initial kitchen tour and concurrent interview with the Front of House Supervisor (FOHS) on 9/5/23, at 9:04 a.m., the FOHS stated the DM was usually off on Friday, Saturday, Sunday, and Monday. The FOHS stated she would help to supervise the kitchen when the DM was not in the facility. She stated her usual responsibility was as a dietary aide. She stated the RD visited the facility once a week and seldom saw her in the kitchen. Residents Affected - Many During an interview with the DM on 9/7/23, at 10:30 a.m., the DM stated he was a resource chef manager for the outsourcing company which contracted with the facility. The DM stated he has been covering for the facility's Dietary Manager position for the past four months. The DM stated he was not certified as a Dietary Services Supervisor or was a Certified Dietary Manager. He added he was not aware he needed to meet the requirements to be in the DM position. He stated the RD would not visit the facility this week and he was not aware she took the time off. During a phone interview with the RD on 9/7/23, at 1:30 p.m., the RD stated she visited the facility once a week per her contract. She stated she mostly did clinical workload, performed a monthly kitchen sanitation audit, and provided a copy to the DM. She stated she would communicate with the DM once every two weeks. The RD stated she did not spend much time in or oversee the kitchen. A review of the DM's employee file confirmed the DM was contracted with an outsourced company and did not indicate a hire date. The file included ServSafe Certification (a certification provided after trained and examined the knowledge of safe food handling) and other certifications provided by the outsourcing company training. A review of the undated DM's job description (JD), it stated, .The Dining Service Director .Education and Experience: .Minimum 3 years related experience and/or training at the Dining Services Director level or equivalent .Bachelor's degree in Food Science, Nutrition, Culinary Arts or Hotel/Restaurant Management .having completed Certified Dietary Management Program preferred . A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H&SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of the facility organizational chart indicated the DM was supposed to supervise the dietary service department and its staff; the RD was not included in the chart. A review of an undated RD's JD indicated the RD's major responsibility was to perform clinical work in the facility. A review of the facility's contract titled RD .Consulting Agreement, signed on 3/12/22, indicated the scope of the RD's duties was consultant based and as a clinical dietitian. It also indicated the RD's hours of work in the facility did not exceed a maximum of eight hours per week. 555645 Page 6 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the [NAME] 1 (CK 1) was unable to verbalize the process of properly cooling down cooked food and was unable to practice safe food handling while preparing food for a census of 29 residents who received food from the facility kitchen. These failures had the potential to cause food borne illness in a potentially compromised population. Findings: During an interview with the CK 1 on 9/6/23, at 9 a.m., the CK 1 explained the cooling down process of the cooked food. The CK 1 stated he would put the cooked meat in the refrigerator to cool down in order to slice the meat easier. He then stated he would reheat the meat to 150 degrees Fahrenheit (F, a unit to measure temperature). In a concurrent review of the cooling log (a log to verify the effectiveness of the cooling process from 140 degrees F to at least 41 degrees F within the maximum cooling period of six hours), the CK 1 stated he had never seen the log and stated he had not followed the cooling process nor used the cooling log since he started working in the facility. During an interview with the Front of House Supervisor (FOHS) on 9/6/23 at 9:08 a.m., the FOHS stated she expected the Cooks to use the cooling log when cooling hot cooked food and expected the Cooks to have the knowledge to reheat the food temperature to 165 degrees F for a minimum of 15 seconds. During an observation of CK 1 making puree food on 9/6/23 at 10:27 a.m., CK 1 used the same soiled dry towel during the following actions: wiped the surface of the food contact counter, removed cooked food from the oven, wiped his gloved hands, wiped the inner sides of a cooking pan with cooked food in it, grabbed a tray of cooked food and touched the surface of the cooked pork slices that were ready for making pork puree. During a follow up observation of CK 1 during the lunch meal distribution on 9/6/23, starting at 11:24 am., CK 1 used the same soiled dry towel (which he placed on the food prep table) and wiped the thermometer probe after he pierced the pork to take its temperature. Then he placed the used thermometer with the ready-to-use clean utensils without properly cleaning it. When CK 1 placed the food on the plate, CK 1 was observed to have used the same towel to wipe off the extra gravy from the plate several times. During an interview with the Dietary Manager (DM) on 9/7/23, at 12:52 p.m., the DM acknowledged CK 1's practices and stated CK 1 lacked food safety knowledge and needed more training. He stated the dietary department only did one in-service about handwashing for the dietary staff. During a concurrent interview and review of CK 1's employee file with the DM on 9/7/23, at 2:05 p.m., the file indicated CK 1's hire date on 3/28/23 and there was no competency or skill set evaluation on file. The DM stated there was no competency or evaluation done for CK 1. He stated CK 1 only had one in-service regarding handwashing. During a follow up interview with the DM on 9/7/23, at 3:55 p.m., the DM stated kitchen staff 555645 Page 7 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many needed to follow the sanitization policy and the towel should either be in a sanitizer bucket soaked with sanitizer solution or it was in use. The DM confirmed Cooks should know and perform food safety and sanitization practices because it could lead to cross contamination and illness. A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .COOLING .Cooling is the process of rapidly bring the temperature of a hot TCS [time/temperature control for safety] food down, through the temperature danger zone, to a safe cold temperature. Inadequate cooling of TCS foods has been consistently identified as on of the leading contributing factors to foodborne illness .cooked TCS foods must be rapidly cooled with 2 hours, from 135 F to 70 F, and within and additional 4 hours from 70 F to 41 F. The cooling process must be documented for each TCS food item cooled .monitor TCS food during the cooling process to ensure that critical limits are not exceeded. Check the food temperature throughout the process. Record cooling times/temperatures on the .cooling log (or equivalent). Retain log for a minimum of 30 days . A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .REHEATING .Reheating is the process of bring TCS foods that were cooked and cooled, back to a temperature that is safe to be served and consumed .TCS foods that are cooked, cooled and then reheated for hot holding or immediate service must be reheated so that all parts of the food reach a minimum internal temperature of 165 F .record final internal temperature of reheated TCS foods onto the TCS food cooking and cooling log (or equivalent) and maintain logs for a minimum of 30 days . A review of the undated departmental policy and procedure, titled .Food Safety & Quality Assurance Standards Manual, indicated, PREVENTING TEMPERATURE ABUSE .THERMOMETERS .MEASURING TEMPERATURE .Clean and sanitize thermometer probes just as you would any other small ware. They should be washed, rinsed, and sanitized after each use. A Sani-Wipe may also be used in lieu of the wash, rinse sanitize process. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .the food service area shall be maintained in a clean and sanitary manner .between uses, cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution . A review of the undated Cook's job description indicated, .Essential Functions and Key Tasks .prepare large quantities of food, following .sanitation standards .maintains basic food recipes, preparation, and service and storage sanitation principles . A review of facility contract agreement with the outsourcing company, titled, Dining Service Management Agreement, signed on 4/3/20, indicated, .Service Standards .[outsourcing company's name] shall comply with all applicable food safety and other federal, state and local laws and regulations. [outsourcing company name] shall maintain high standards of sanitation in provision of Dining Services .Training: [outsourcing company name] shall provide all Dining Services related training to Dining Services personnel . 555645 Page 8 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician.) during the lunch meal on 9/6/23 when: 1. Six residents (Residents: 4, 6, 11, 23, 27, and 29) with small portion and/or consistent carbohydrate (CCHO, a diet to help keep blood sugar levels stable) received half of a white roll instead of a whole white roll; 2. Nine residents (Residents: 3, 5, 9, 11, 15, 20, 21, 25, and 29) with mechanical soft texture diets (chopped or ground food prescribed to those who have trouble chewing and swallowing) received whole spears of asparagus and sweet potato with the peel instead of diced asparagus and sweet potato without the peel; 3. 14 residents (Residents: 1, 2, 6, 7, 8, 13, 16, 17, 18, 19, 22, 24, 26, and 28) who were not on CCHO and/or small portion diets got two ounces (oz, a unit of measurement) of tapioca pudding instead of four oz.; 4. Three residents (Resident 10, 12, and 14) with small portion puree texture diets (blended smooth and prescribed for people who have trouble chewing or swallowing) got four oz. pureed sweet potato and four oz. of pureed asparagus instead of two oz. of pureed sweet potato and pureed asparagus; and, 5. One resident (Resident 19) with an ordered pureed texture diet got a bowl of regular texture salad. These failures decreased the facility's potential to ensure residents received the nutrition they needed in a safe manner for a census of 29 residents. Findings: 1. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the Diet Aide (DA) served six residents with prescribed small portion and/or CCHO diets half of a white roll. A concurrent review of the facility's prescribed diet menu titled, Extensions: Wednesday, Week 1 . 2023, to be served on 9/6/23, indicated a white roll should have been served to residents with CCHO and small portion diets. 2. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the [NAME] (CK 1) served nine residents with prescribed mechanical soft texture diets whole spears of asparagus and sweet potato with the peel. A review of the facility's prescribed diet menu titled, Extensions: Wednesday, Week 1 .2023, to be served on on 9/6/23, indicated diced steamed asparagus and baked sweet potato without the peel should have been served to residents with mechanical soft diets. 555645 Page 9 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the DA served 14 residents two oz of tapioca pudding who were not on CCHO and/or small portion diets. A review of the facility's prescribed diet menu, titled Extensions: Wednesday, Week 1 .2023, to be served on 9/6/2023, indicated diets that were not CCHO and/or small portion should be served four oz. of tapioca pudding. During an interview on 9/6/23 at 11:58 a.m., the DA stated she had prepared only two oz. portions instead of four oz. portions of tapioca pudding for the 9/6/23 lunch service, because there was not enough tapioca pudding to make the four oz. sized portions. 4. During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., the CK 1 served three residents four oz. puree sweet potato and four oz. of puree asparagus with use of a #8 scoop (a four oz. serving utensil) who were prescribed small portion puree texture diets. A review of the facility's prescribed diet menu, titled Extensions: Wednesday, Week 1 .2023, to be served on 9/6/2023, indicated small portion puree texture diets should have been served two oz. puree sweet potato and two oz. puree asparagus. 5. A review of Resident 19's quarterly Minimum Data Set (an assessment tool), dated 7/25/23, indicated Resident 19 was admitted to the facility in October of 2018 and diagnosed with Parkinson's disease (causes uncontrollable movements and difficulty with coordination) and dysphasia (difficulty swallowing). A review of Resident 19's lunch tray ticket dated 9/6/23, indicated, .Do Not Serve .Salad Garden . During an observation of the lunch service on 9/6/23, beginning at 11:25 a.m., Resident 19 received a bowl of regular texture salad. During an interview on 9/6/23 at 12:12 p.m., the Dining Services Director (DSDS) stated small portion and CCHO diets should have had one whole roll per the menu extension. The DSDS also stated the kitchen staff needed to follow the menu, menu extensions, and resident tray tickets (the ticket on the meal tray which indicate the resident's prescribed diet order, likes, dislikes, and allergies) to give the correct foods and to ensure residents received the correct portions because it affected the residents' nutritional intake. The DSDS also acknowledged Resident 19 was prescribed a puree texture diet and received a regular texture salad. The DSD stated she went to Resident 19's room and saw Resident 19 had taken a bite of the salad. The DSD added kitchen staff needed to follow the menu and tray ticket to ensure the residents received the correct form of food to prevent choking. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated the cooks and kitchen staff needed to follow the menu and menu extensions for compliance with the diet orders, portions, and food textures for each resident. A review of the undated facility document titled, Diet Aide Job Description, indicated, .The Diet Aide assembles meals and serves food under the direction of the [DSDS] or manager .Essential Functions and Key Tasks .Assembles snacks and nourishments according to .client orders . A review of the undated facility document titled, Cook Job Description, indicated, .As the cook you will have responsibility of food production in the kitchen operations .Essential Functions and Key 555645 Page 10 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0803 Tasks .Prepare large quantities of food, following standardized recipes .Maintains basic food recipes, preparation and service . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 555645 Page 11 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when: Residents Affected - Many 1. Food items were found with missing or incorrect labels and dates; 2. Food items found expired and available for use; 3. A food item was found opened and uncovered to prevent cross contamination (the unintentional transfer of bacteria and substances from one food to another); 4. Trays of prepared food were found uncovered, unlabeled and/or undated; 5. Drawers which stored clean ready-to-use utensils were dirty and one was broken; 6. Ice machines in the kitchen and in the nourishment room were not clean; 7. A juice dispenser was not cleaned per the manufacturer's instruction; 8. One Dishwasher did not perform the sanitizer concentration recording appropriately; and, 9. One [NAME] was unable to verbalize the proper cooling down process and did not perform safe food handling practices during food preparation. These failures decreased the facility's potential to prevent food-borne illness in a highly susceptible population for a census of 29 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., the following food items were found opened and without labels (stickers on the packages to indicate the opened date and expiration date): -a bag of shredded Mozzarella cheese, -a block of cream cheese, -a bag of macaroni noodles, -a bag of spaghetti noodles, -a bag of penne pasta, -a bag of egg noodles, -a bin of chocolate chips, 555645 Page 12 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 -a jar of red chili in oil, Level of Harm - Minimal harm or potential for actual harm -a box of tofu, -a jar of ranch dressing, he Residents Affected - Many -a package of wonton wrappers, and, -a bottle of fish sauce. During a concurrent observation and interview on 9/5/23, at 10:56 a.m., the Front of House Supervisor (FOHS) inspected all the opened packages listed above and confirmed all the items were opened and were missing a label. The FOHS added per their policy all opened packages of food products should be labeled with the date they were opened. In an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated he expected kitchen staff to label all opened food products with: the name of the product, the date the item was opened/prepared, and to refer to the food storage chart and mark the date the product will expire. A review of the facility's policy titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .Cover, label and date unused portions and open packages .products are good through the close of business on the date noted on the label .refer to the food storage chart in this policy to determine discard dates for food items . 2. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m. the following expired food items were available for use in the dry storage room and reach-in freezer: -a bin of oatmeal labeled with an expiration date of 8/15/23, -a bin of flour labeled with an expiration date of 2/11/23, -a bin of sweetened coconut labeled with an expiration date of 2/6/23, and -a tray of mango sorbet labeled with an expiration date of 8/24/23. During a concurrent observation and interview on 9/5/23 at 10:56 a.m., the FOHS inspected all the expired packages listed above and confirmed all of the items were expired. The FOHS stated those items should not be available for use and added, if someone ate expired food, they could get sick. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to discard expired foods and ensure no expired foods were in food storage areas. A review of the facility's policy titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .discard food past the 'use by', 'sell-by', 'best-by', or 'enjoy by' date .Cover, label and date unused portions and open packages . products are good through the close of business on the date noted on the label . 3. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., an opened package of butter was found on the shelf in the reach-in refrigerator. The butter was not fully wrapped and had a brown 555645 Page 13 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 substance on it. Level of Harm - Minimal harm or potential for actual harm During a concurrent follow up observation and interview on 9/5/23 at 2:55 p.m., the FOHS confirmed the butter was not properly wrapped and had evidence of cross contamination. Residents Affected - Many During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to put opened packages of food in a closed container and to have followed policies on covering foods to prevent cross contamination. 4. During a kitchen tour on 9/5/23 starting at 8:58 a.m., the following food items were found prepared, uncovered, unlabeled, and/or undated: -a tray of cups filled with red liquid without a label or date, -a tray of plastic containers filled with a white creamy substance was uncovered and without a label or date, and -four trays of brown triangular shaped food were not covered and without a label or date. During a concurrent observation and interview on 9/5/23, at 9:36 a.m., the FOHS inspected the tray of cups with red liquid and stated they were prepared soup to be served to the skilled nursing residents. The FOHS confirmed they were not labeled or dated. During a concurrent observation and interview on 9/5/23 at 9:40 a.m., the FOHS inspected the tray of plastic containers filled with a white creamy substance and stated they were prepared ranch dressing and confirmed they were uncovered, unlabeled, and undated. During a concurrent observation and interview on 9/5/23 at 9:36 a.m., the [NAME] 1 (CK 1) inspected four trays of brown triangular shaped food and stated they were prepared, breaded frozen tilapia . pulled from the freezer this morning. The CK 1 confirmed the prepared tilapia was not covered, unlabeled, and undated. The CK 1 added, they should have cover, label and sticker with date. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected the kitchen staff to follow the policy to either cover the entire rack or individual trays of prepared food to prevent cross contamination that could lead to illness. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, .PREVENTING CONTAMINATION .FOOD STORAGE .All food shall be stored in such a manner as to prevent contamination and maintain the safety and a wholesomeness of the food for human consumption .Foods that have been opened or processed must be stored in NFS [National Sanitation Foundation] approved containers with tight-fitting lids (where appropriate) or covered or otherwise protected from overhead/environmental contamination . A review of the facility's policy and procedure titled, CULINARY & SUPPLY CHAIN, revised December 2020, indicated, .Cover, label and date unused portions and open packages . 5. During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., there were two drawers which stored clean and ready-to-use food serving utensils. Both drawers were dirty with food debris and one of the drawers was broken with two holes in the bottom. 555645 Page 14 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 9/7/23 at 3:55 p.m., the DM confirmed the utensil drawers with debris and holes in the bottom were not acceptable per policy due to the risk of cross contamination. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .The food service area shall be maintained in a clean and sanitary manner .all utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks . 6. During an inspection of the ice machine in the kitchen on 9/5/23, at 11:09 a.m., the Maintenance Director (MD) removed the ice machine's top access panel to reveal the water curtain (a white plastic cover to direct the ice into the storage bin). Upon removal of the water curtain, there were orange-pink and black gelatinous substances covering a large portion inside of the curtain. During a concurrent interview, the MD stated the facility hired an outside vendor who sent their technician to deep clean (sanitize the machinery and the storage bin) the ice machine, but he was not sure how often the outside vendor's technician was scheduled to clean it. The MD added, he needed to wait until the technician came to dissemble other parts of the ice machine. During a concurrent observation and interview on 9/5/23 at 11:12 a.m., at the kitchen ice machine, the FOHS confirmed the presence of the substances found on the water curtain and stated the ice machine was not kept in clean and sanitary condition. She also stated the kitchen staff were not responsible for cleaning the ice machine. During an interview on 9/5/23 at 11:15 a.m., the FOHS stated there was another ice machine located in the nourishment room at the nursing station, and the facility maintenance was responsible for maintaining and cleaning it. During an inspection of the ice machine in the nourishment room on 9/5/23, at 3:42 p.m., the MD acknowledged there was an orange, slimy substance, which could easily be wiped off with a paper towel from the chute (the passage through which ice dispenses) of the ice machine. The MD removed the ice machine's top access panel to reveal the water curtain and stated he could not remove the water curtain because he thought he would break it if he tried. The water curtain was able to be pulled forward while still attached and a black substance was visualized on the inside of the water curtain and on the water trough (a component that holds the water before it is frozen during the ice making process). The MD stated the facility's maintenance staff were responsible for monthly cleaning of the exterior of the ice machine and an outside vendor performs the interior cleaning cycles. The MD added, he was not able to say if the ice machine was clean or not. During a follow up inspection of the ice machine in the nourishment room on 9/6/23 at 8:36 a.m., the Outside Vendor Technician (OVT) removed: the ice machine's top access panel, water curtain, and water trough. The water curtain and water trough had significant amounts of a black gelatinous substance, both sides and bottom of the evaporator plate (the cold surfaces within the ice maker where ice is formed) had an orange-pink slimy substance. During a follow up inspection of the ice machine in the kitchen on 9/6/23, at 8:50 a.m., the OVT removed the water trough to reveal significant black gelatinous substance, which could be easily wiped off with a paper towel, on the bottom of the ice evaporator unit and on the bottom of the water trough. 555645 Page 15 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 9/6/23 at 10:20 a.m., the OVT stated the outside vendor company has a contract with the facility to perform ice machine cleaning every six months. During an interview on 9/7/23, at 3:55 p.m., the DM stated the pink and black substances were mold and the ice machines, were not being cleaned as often as they should be. Residents Affected - Many A review of the undated kitchen ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. CLEANING/SANITIZING PROCEDURE .must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized .Remove mineral deposits from areas or surfaces that are in direct contact with water. PREVENTATIVE MAINTENANCE CLEANING PROCEDURE .This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure without removing the ice from the bin/dispenser . A review of the nourishment room ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, dated June 2017, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual .Cleaning /sanitizing procedure .must be performed a minimum of once every six months. The ice machine and bin must be disassembled cleaned and sanitized .remove mineral deposits from areas of surfaces that are in direct contact with water. Preventative maintenance cleaning procedure .This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure . A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, The food service area shall be maintained in a clean and sanitary manner . ice machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions . 7. During a concurrent observation, interview, and machine instruction review on 9/5/23, at 11:23 a.m., the FOHS opened the juice dispenser machine to reveal the dispenser nozzles with built-up orange and pink substances on them and a panel with written instructions for cleaning the juice dispenser. The FOHS stated the juice dispenser nozzles were removed and cleaned once a week. The FOHS then looked at the written instructions on the inside panel of the juice dispenser that indicated the nozzles should be removed and cleaned daily and stated the machine is not being cleaned per manufacturer's directions. During an interview on 9/7/23, at 3:55 p.m., the DM stated he expected kitchen staff to clean the juice dispenser nozzles daily per the manufacturer instructions to prevent buildup but acknowledged the juice dispenser was not included on the assigned cleaning schedules. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, SANITATION .MAINTAINING SANITARY CONDITION .Effective sanitation prevents the growth of microorganisms .equipment, food-contact surfaces, and utensils must be clean to sight and touch .non-food contact surfaces must be kept free of an accumulations of dust, dirt, food residue and other debris .must be cleaned as often as necessary to keep them clean .clean food and non-food contact surfaces that have an accumulation of soils outside of their proper cleaning frequency 8. During a concurrent observation and interview on 9/5/23 at 10:25 a.m., the dishwasher (DW) 555645 Page 16 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 Level of Harm - Minimal harm or potential for actual harm stated the test strips to test the sanitizer concentration, went missing a couple of days ago .I didn't test the sanitizer today. I went off what it was before as he pointed to the September sanitizer test log hanging on the wall. The log had been filled out for 9/5/23 for the 5:30 a.m., 12 p.m., and 2 p.m. time slots. Each time slot was documented with a sanitizer level of 200 ppm (part per million: a unit of measure for the sanitizer concentration). Residents Affected - Many During an interview on 9/5/23, at 10:38 a.m., the FOHS stated the sanitizer log should be filled out after testing the sanitizer solution with the test strips, the sanitizer log should not be filled out ahead of time, and, if you don't have a way to test it, you can't log it. During an interview on 9/7/23, at 10:45 a.m., the DM stated the sanitizer log should be filled out three times daily when the sanitizer buckets were prepared and tested. The DM also stated he expected kitchen staff to have documented not tested on the log if the sanitizer was not tested. The DM confirmed the sanitizer log should not have been prefilled out on 9/5/23. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, SANITATION .SANITIZER BUCKETS/BOTTLES WIPING CLOTHS .wet wiping cloths must be stored at all times in an approved quat [quaternary ammonium compound] within the effective range .between 200-400 ppm .test sanitizer concentration .throughout the day to ensure they are maintained at the effective concentrations . 9. During a concurrent observation and interview on 9/6/23, at 9 a.m., CK 1 explained the cooling down process of cooked foods. CK 1 stated he cooked meats in the mornings then would take the meat from the oven and put it in the refrigerator to cool it down to room temperature or colder, he would then remove the cooled meat from the refrigerator to slice, and then would reheat the meat to 150 degrees Fahrenheit (F: a unit of measure for temperature) to serve for lunch. CK 1 reviewed a binder on a prep station that had instruction for cooling foods and a cooling log and stated, First time I have seen a cooling log and that he had not followed or used a cooling log while working in the facility. During an interview on 9/6/23, at 9:08 a.m., the FOHS stated she expected the cooks to use cooling logs when cooling hot foods and expected reheated meats/foods to be heated to 165 F for a minimum of 15 seconds. During an observation of the puree food making on 9/6/23, at 10:27 a.m. CK 1 used the same soiled dry towel to: wipe the surface of a food contact counter, take out cooked food from the oven, wipe his gloved hands, wipe the inner sides of a cooking pan that touched food, grab the tray of cooked food and the soiled dry towel touched the surface of cooked pork slices that were ready for making pork puree. During a follow up observation in the kitchen on 9/6/23 starting at 11:24 a.m. CK 1 checked the temperature of the pork. He pierced the pork with the thermometer probe and then wiped the thermometer probe with a dry towel that had been sitting on the prep table (not in a bucket of sanitizer solution) and then put the thermometer with other ready to use cooking utensils. While serving lunch plates, CK 1 wiped off gravy from the plate of a lunch meal with the same dry towel he used to wipe the thermometer with. During an interview on 9/7/23, at 3:55 p.m., the DM stated kitchen staff were expected to follow the sanitization policy, towels were expected to be either in a sanitizer bucket soaked in sanitizer 555645 Page 17 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many solution or actively in use. The DM also stated, cooks specifically should know and perform food safety and sanitization practices to prevent cross contamination and illness. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, PREVENTING TEMPERATURE ABUSE .COOLING .Cooling is the process of rapidly bring the temperature of a hot TCS [time/temperature control for safety] food down, through the temperature danger zone, to a safe cold temperature. Inadequate cooling of TCS foods has been consistently identified as one of the leading contributing factors to foodborne illness .cooked TCS foods must be rapidly cooled within 2 hours, from 135 F to 70 F, and within and additional 4 hours from 70 F to 41 F. The cooling process must be documented for each TCS food item cooled .monitor TCS food during the cooling process to ensure that critical limits are not exceeded. Check the food temperature throughout the process. Record cooling times/temperatures on the .cooling log (or equivalent). Retain log for a minimum of 30 days . A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, PREVENTING TEMPERATURE ABUSE .REHEATING .Reheating is the process of bring TCS foods that were cooked and cooled, back to a temperature that is safe to be served and consumed .TCS foods that are cooked, cooled and then reheated for hot holding or immediate service must be reheated so that all parts of the food reach a minimum internal temperature of 165 F .record final internal temperature of reheated TCS foods onto the TCS food cooking and cooling log (or equivalent) and maintain logs for a minimum of 30 days . A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, undated, indicated, PREVENTING TEMPERATURE ABUSE .THERMOMETERS MEASURING TEMPERATURE .Clean and sanitize thermometer probes just as you would any other small ware. They should be washed, rinsed, and sanitized after each use. A Sani-Wipe may also be used in lieu of the wash, rinse sanitize process . A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .the food service area shall be maintained in a clean and sanitary manner .between uses, cloths and towel used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution . 555645 Page 18 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpsters, located outside the facility, were not secure with the dumpster lids closed. Residents Affected - Many This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 9/6/23 at 9:15 a.m., the facility's outside garbage dumpster lids were open, there were bags of garbage in the dumpster bin and trash was scattered on the ground around the dumpster bin. The Front of House Supervisor (FOHS) stated. [the dumpster] is supposed to be closed at all times to keep pests out of it. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager (DM) stated he expected the dumpster area to be kept clean and dumpsters should have been closed with tight fitting covers per their policy and to prevent pest and rodent activity. A review of the undated departmental policy and procedure titled, .FOOD SAFETY & QUALITY ASSURANCE STANDARDS MANUAL, indicated, FACILITY DESIGN & MATERIALS MANAGEMENT .GARBAGE, UTILITY SINK & SEWAGE DISPOSAL .Garbage and refuse storage containers, including dumpsters, must have tight-fitting lids or covers . A review of 2022 Federal Food Code, dated 1/18/2023, indicated, .Outside Receptacles .Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers . 555645 Page 19 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program for one of 13 sampled residents (Resident 1) when hand hygiene was not performed during medication administration and an eye drop was not handled with infection control precautions. These failures had the potential to result in transmission of infection in the facility for all 29 residents. Residents Affected - Few Findings: During a medication pass observation on 9/5/23 at 9:16 a.m. with Licensed Nurse 1 (LN 1), the LN 1 was observed preparing to administer medications to Resident 1, including a Brand Name eye lubricant eye drop. The LN 1 put on a pair of gloves, opened a binder that contained medical records and flipped through multiple pages before closing it. With the same gloves, LN 1 picked up Resident 1's medications and entered the resident's room. LN 1 removed the cap from the eye drop bottle and placed it directly on Resident 1's bedside table, next to her breakfast tray. LN 1 then administered two drops into each of Resident 1's eyes, all without changing gloves or performing hand hygiene. During an interview on 9/5/23 at 11:06 a.m. with LN 1, LN 1 stated nursing staff were expected to wash their hands or use hand sanitizer between medication administration. He stated it was acceptable to use the same gloves used to review medical records in the binder to administer medication because, Everything on the [medication] cart is considered clean. He stated he believed the bedside table was a clean enough surface to place the eye drop cap on, because we put [the resident's] food on it. LN 1 stated it would have been better nursing measures to have placed the cap on a napkin or to have held onto it. During an interview on 9/5/23 at 2:56 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to perform hand hygiene anytime they touched a resident. She stated gloves were to be changed after touching medical records and before performing direct resident care. DON stated nursing staff were to wash their hands and wear new gloves before administering an eye drop. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Eye Drops, dated October 2007, the P&P indicated, Procedures .Perform hand hygiene .Remove the cap . place cap on a clean, dry surface (such as a tissue or gauze). During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated August 2015, the P&P indicated, Policy Interpretation and Implementation .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents .Before preparing or handling medications .Before donning sterile gloves .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene . 555645 Page 20 of 21 555645 09/08/2023 Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition and good repair when one reach-in freezer had a torn gasket and ice buildup. Residents Affected - Few This failure had the potential to result in the freezer not holding proper temperatures for frozen foods stored inside. Findings: During an initial kitchen tour on 9/5/23 starting at 8:58 a.m., the reach-in freezer was found to have a torn gasket (a seal around the door that helps keep the cold air in and warm air out) and ice buildup (an accumulation of ice that occurs when warm or humid air flows into a freezer). During a concurrent observation and interview on 9/5/23 at 10:56 a.m., the Front of House Supervisor (FOHS) confirmed the reach-in freezer had a torn gasket and ice buildup. The FOHS added, the torn gasket made the freezer door not shut properly and could negatively affect the frozen food. During an interview on 9/7/23 at 3:55 p.m., the Dietary Manager stated the reach-in freezer gasket needed to be replaced to prevent ice buildup and maintain freezer temperature. A review of the facility policy and procedure titled, Sanitization, revised October 2008, indicated, .equipment shall be kept clean, maintained in good repair and shall be free from breaks .open seams .seals .will be kept in good repair . 555645 Page 21 of 21