Health inspection·April 11, 2019

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure that each resident received food that was palatable, and at a safe appetizing temperature, when temperatures of pureed chicken and pureed vegetables were taken and too low. The pureed chicken and vegetables were placed back on the stove to re-heat. Charge [NAME] K, Dietary Aide M, and Training [NAME] L immediately used the reheating foods by placing these foods on plates to be served. No temperature of the pureed chicken or vegetables was re-taken to ensure it was at proper holding temperature on the steam table, or had been raised to a palatable temperature for consumption. Residents Affected - Some This failure had the potential to allow potentially hazardous foods (PHF) served to residents resulting in food borne illness, or to have them be over-heated and potentially scald residents. Findings: During an observation and concurrent interview on 4/10/19 from 11:30 a.m. to 12:00 p.m., the temperature of the pureed chicken was 110 degrees F, and pureed vegetables was 118 degrees F. Charge [NAME] K placed the food containers with pureed chicken and pureed vegetables back on the stove to heat them to acceptable temperatures (Per Training [NAME] L interview the acceptable temperatures were 165 degrees for the chicken, and 135 for the vegetables.) Dietary Aide M removed pureed chicken and pureed vegetables immediately after they were placed onto the stove for re-heating, in Charge [NAME] K's presence. There were 11 additional plates prepared for serving from the foods re-heating. No temperatures were taken of the re-heating food prior to placing food onto the plates. Charge [NAME] K was asked why the temperatures were not re-taken, she stated it just slipped her mind. The facility policy and procedure titled Food Service Management, dated 1/1/17, indicated: .Hot food items shall be held at 140 degrees F or above and served at not less than 120 degree F at bedside or in dining room to ensure serving temperatures are palatable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 2 of 5 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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)

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 facility document review, the facility failed to ensure food safety requirements were followed when; Residents Affected - Many 1. Gallon sized salad dressings in the walk-in refrigerator were not labeled correctly with date opened and use-by dates. 2. A large bin of meats defrosting held two open packages of meat without label or date. 3. The freezer had link sausage stored in thin bags, the bags were cracked, and open with meat protruding out of them, and 3 bags were not labeled or dated. 4. During tray-line the pureed chicken, and vegetables were tempted at 110/118 degrees (F) Fahrenheit respectively. Both the chicken and vegetables were placed back on the stove to cook, but not re-tempted before plating. 5. Dietary staff did not demonstrate proper testing of Quationary solution, and used expired test strips. 6. The ice machine scooper was handled by staff with bare hands, re-introduced into the ice bin, and staff continued to use it without sanitizing it. These failures had the potential to cause growth of bacteria, cross-contamination, and food-borne illness in residents. Findings: 1. During an observation and concurrent interview on 4/8/19 at 10:20 a.m., two 1 gallon containers of salad dressing were in the refrigerator dated with only one date (3/15/19). When questioned as to the date's meaning, Administrative Staff C and Administrative Staff D stated the date on refrigerated items was the use-by date, but staff should place open and use-by dates on all containers. During an observation and concurrent interview on 4/8/19 at 3:30 p.m., re-check of label in refrigerator for the two items found with questionable date additional containers were found with one single date for dressings. Repeated requests for the labels of items found in refrigerator in order to see the manufacturer's expiration date were made, but they were not provided. 2. During an observation and concurrent interview on 4/8/19 at 10:23 a.m., a large bin with several meats in a second walk-in refrigerator was being held . Two of the meat packages were open without label or date. When questioned as to why the meats were not labeled with date, Administrative Staff C stated that this was not part of their supply. It belonged to the Independent Living side. There was no separation sign or indication in any food supply area was off limits to either Independent Living or Skilled Nursing staff of the kitchen observed. During the tray-line observation on 4/10/19 at 11:42 a.m., Training [NAME] L was asked what happens (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 3 of 5 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many if supply of a menu item runs out. Training [NAME] L stated the staff could get it from the other side (the independent side). 3. During an observation and concurrent interview on 4/8/19 at 10:28 a.m., in the freezer there was a large bin of link sausages in thin bags. One of the bags was cracked and open in several places and had links sticking out of the openings. That bag and two other bags were not labeled, or dated. Administrator D stated that it should be labeled. 4. During an observation and concurrent interview on 4/10/19 from 11:30 a.m. to 12:00 p.m., the temperature of the pureed chicken was 110 degrees F, and pureed vegetables was 118 degrees F. Charge [NAME] K placed the food containers with pureed chicken and pureed vegetables back on the stove to heat them to acceptable temperatures (Per Training [NAME] L interview the acceptable temperatures were 165 degrees for the chicken, and 135 for the vegetables.) Dietary Aide M removed pureed chicken and pureed vegetables immediately after they were placed onto the stove for re-heating, in Charge [NAME] K's presence. There were 11 additional plates prepared for serving from the foods re-heating. No temperatures were taken of the re-heating food prior to placing food onto the plates. Charge [NAME] K was asked why the temperatures were not re-taken, she stated it just slipped her mind. 5. During an observation and concurrent interview on 4/8/19 at 3:45 p.m. Dietary Staff E, F, and G were asked to demonstrate test to ensure quationary solution used to clean food preparation surfaces was at appropriate level. Dietary Staff E, and G had not read the instructions, and had not held test strip in quaternary solution for the proper amount of time. The test strip had an expiration date of 5/15/15, but was still in use. When questioned about the expiration date, Dietary Staff F stated these were the only test strips he had seen, and the test strips he always used. 6. During the initial brief kitchen tour of the facility on 4/8/2019, at 10:57 a.m., Dietary Aide I passed in front of this surveyor holding on to an ice scooper. Dietary Aide I was ready to empty the ice contents of the ice scooper to a large plastic dish pan that contained foods that were in plastic storage containers. Dietary Aide I, with bare hands, one hand was on to the handle of the ice scooper and her other hand was holding the bottom part of the scooper, the part which actually scoops the ice from the ice machine. After the ice scooper was emptied, Dietary Aide I walked toward Dietary Aide J and handed her the ice scooper. Dietary Aide J, who was preparing beverages during this time, used the same ice scooper to scoop ice from the ice machine and placed the ice on the pitchers that were lined in front of her. Dietary Aide J filled these pitchers with water and juices. During an interview with Administrative Staff C, and witnessed by Administrative Staff D on 4/11/19, at 3:20 p.m., Administrative Staff C stated that the facility did not have a policy regarding the proper handling of the ice scooper. She also stated that the facility did not require dietary staff to wear gloves when using the ice scooper to get ice from the ice machine. Administrative Staff C was asked if they allowed the bare hands of the dietary staff to handle the bottom part of the ice scooper which came into contact with the ice contents of the ice machine, she stated that this practice was not acceptable. The facility policy titled Food Service Management, dated 1/1/17, indicated: .Sanitizer buckets are filled with warm water and an appropriate sanitizer at a high concentration to ensure that the solution stays effective (Quat ppm [parts per million] at 200 or bleach/chlorine at 100 ppm) Test concentration of sanitizer with appropriate test strip and document. The policy and procedure titled Food Service Management, dated 1/1/17, indicated: Policy. To (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555727 If continuation sheet Page 4 of 5 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 555727 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurel Creek Health Center 2800 Estates Drive Fairfield, CA 94533 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete provide a means for the safe storage of refrigerated items that have been opened and may not be in their original container. 1. Any foods removed from original container will be properly labeled as follows: The name of the food item being stored and the date the food was removed from its original container and stored. 2. Foods must be stored in approved food storage container .Most commercially processed foods are safe until their expiration or 'use by' date on the label, .Exceptions that require a Seven Day-Date mark rule: Commercially processed foods that are not pH adjusted, must be dated when opened and are good for 7 days, or until the expiration date (such as milk, cottage cheese and soft cheese) .Labeling/Date marking frozen foods. a. Frozen food is to be used within 90 days. Most frozen foods have delivery dates. When foods do not, or when food that is produced in the facility is frozen, label with current date (will be day 1). Event ID: Facility ID: 555727 If continuation sheet Page 5 of 5