Health inspection·March 8, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 properly label and store COVID-19 (a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2) rapid test kits when the kits stored in one medication cart had expired. This failure had the potential to cause inaccurate test results which could have put the residents at risk for inappropriate care and treatment based on the test results. Findings: During a concurrent observation and interview, on 3/7/24, at 9:52 AM, at Medication Cart One, the Assistant Director of Nursing (ADON) opened the locked cart. In the bottom drawer were four boxes of COVID-19 Antigen (any substance that caused the body to make an immune response against that substance) Rapid Test kits. Each box contained two tests. ADON confirmed the expiration date printed on the boxes was 9/6/23. The lot number was 221CO20907. The United States Food and Drug Administration Authorized At-Home Over-the-Counter Diagnostic Tests and Expiration Dates table, located online at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests#list, was reviewed. The table contained a list of various manufacturers' COVID-19 testing kits, information about the tests, links to directions for use, expiration dates and expiration date extensions based on lot numbers. The table indicated that for test lot number 221CO20907, with a printed expiration date of 9/6/23, the expiration date had been extended to 12/6/23, which had already passed. Page 1 of 6 555776 555776 03/08/2024 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on in interview and record review the facility failed to provide the residents food that is palatable (tasty, and flavorful), visually pleasing presentation, and an appetizing temperature for 23 of 47 residents (Residents: 53, 39, 28, 42, 35, 63, 24, 50, 16, 27, 52, 40, 58, 33, 56, 4, 59, 6, 5, 32, 18, 9, and 22) when residents complained of food not tasting good, visually unappealing/unrecognizable presentation, and being cold on a regular basis. Residents Affected - Some This failure had the potential to result in residents not obtaining adequate nutritive intake, precarious weight loss, increased health issue complications, and diminished emotional well-being. Findings: During a record review of the facility's policy and procedure titled, Food: Quality and Palatability, Revised 9/2017, the Food: Quality and Palatability policy indicated, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature . 1.A review of Resident 53's medical record indicated that resident 53 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, High Blood Pressure, Peripheral Vascular Disease (PVD, Circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During an interview on 3/5/24 at 9:50 am, with Resident 53, stated, Food is not good. (Related to all food) All things, not good. Every day is scrambled eggs. Taste like Hell. 2.A review of Resident 39's medical record indicated that resident 39 was admitted on [DATE] with diagnoses that included, Degenerative Disease of the Basal Ganglia (Rare disease, over time, causing areas of the brain to shrink, nerve cells break down and die affecting areas of the brain that process information and control movement), High Blood Pressure, Intervertebral Disc Degeneration (Breakdown of one or more of the discs that separate the bones of the spine) During an interview on 03/05/24 9:50 am, with Resident 39, stated, always get scrambled eggs. every day is scrambled eggs, never changed. (Food) Temp is cold. 3.A review of Resident 28's medical record indicated that resident 28 was admitted on [DATE] with diagnoses that included, Fracture of the fifth lumbar vertebra, Diabetes Mellitus, High Blood Pressure. During an interview on 03/05/24 1:55 pm, with Resident 28, stated, The flavor is not good. I need lots of salt in the food (to eat it). the gravy isn't good. The problem is food .no salt, no eat, (I go) hungry . 4.A review of Resident 42's medical record indicated that resident 42 was admitted on [DATE] with diagnoses that included, Anoxic Brain Damage (Blood flow is disrupted to the brain causing complete, lack of oxygen resulting in death of brain cells), Chronic Obstructive Pulmonary Disease (COPD, inflammatory lung disease that block airflow and make it difficult to breathe), Congestive Heart Failure (CHF, heart muscle does not pump blood effectively). 555776 Page 2 of 6 555776 03/08/2024 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 3/5/24 at 10:09 am, with Resident 42, stated, (The food is) Bland, no flavor, not good. 5.A review of Resident 35's medical record indicated that resident 35 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, Non-ST Elevation Myocardial Infarction (NSTEMI, less severe form of heart attack, inflicting less damage on the heart), COPD. During an interview on 03/05/24 9:50 am, with Resident 35, stated, The food is the main issue, no taste. 6.A review of Resident 63's medical record indicated that resident 63 was admitted on [DATE] with diagnoses that included, Acute Embolism and Thrombosis of Unspecified Deep Veins of Bilateral Lower Extremities (Blood clots forming in deep veins of the legs blocking blood flow), Polyneuropathy (Many nerves outside the brain and spinal cord are damaged causing weakness, numbness, and pain), and High Blood Pressure. During an interview on 03/05/24 10:15 am, with Resident 63, stated, Food is unrecognizable. 7.A review of Resident 24's medical record indicated that resident 24 was admitted on [DATE] with diagnoses that included, Dementia, Benign Prostatic Hyperplasia (BPH, Age related condition where the prostate becomes enlarged. The prostate is a small gland that helps make semen, found below the bladder, the enlargement results in blocking the flow of urine out of the bladder), Malignant Neoplasm of Colon (Colon cancer). During an interview on 03/05/24 10:15 am, with Resident 24, stated, Food is sometimes ok. I am not able to recognize what it is .I do not like to eat what I do not know what is. I can't recognize (the food) at all. I have told them when it isn't hot .I do not return food, I just try to eat it, or I just don't eat. 8.A review of Resident 50's medical record indicated that resident 50 was admitted on [DATE] with diagnoses that included, Cerebral Infarction (stroke), Hemiplegia and Hemiparesis following Cerebral Infarction (weakness and paralysis on one side of the body)), Malignant Neoplasm of breast (Breast cancer). During an interview on 03/05/24 10:42 am, with Resident 50, stated, (Food is) Yuck. 9.A review of Resident 16's medical record indicated that resident 16 was admitted on [DATE] with diagnoses that included, COPD, Diabetes Mellitus, Hyperkalemia (High Potassium levels in the blood). During an interview on 03/05/24 10:45 am, with Resident 16, stated, I am on specified diet, I am not supposed to have process food. but everything they offered me is processed food. I would be going hungry .every single meal I have gravy and mash potato for breakfast, they told me I cannot have greens, but they still gave it to me. They are not consistent .often it doesn't taste good. 10.A review of Resident 27's medical record indicated that resident 27 was admitted on [DATE] with diagnoses that included, Fracture of Lumbar Vertebra, Heart Failure, Atrial Fibrillation (A Fib, Irregular often rapid heart rate that causes poor blood flow, the heart's upper chamber beat out of coordination with lower chambers). 555776 Page 3 of 6 555776 03/08/2024 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/05/24 10:48 am, with Resident 27, stated, I got scrambled eggs every day. Food is cold. 11.A review of Resident 52's medical record indicated that resident 52 was admitted on [DATE] with diagnoses that included, COPD, Unspecified Protein- Calorie Malnutrition (nutritional status with reduced availability of nutrients), High Blood Pressure. During an interview on 3/5/24 at 10:54 am, with Resident 52, stated, The food isn't what I like (taste). 12.A review of Resident 40's medical record indicated that resident 40 was admitted on [DATE] with diagnoses that included, Paroxysmal A Fib, High Blood Pressure, PVD. During an interview on 03/05/24 11:15 am, with Resident 40, stated, The food is not very good, but I eat it. 13.A review of Resident 58's medical record indicated that resident 58 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, Muscle Weakness, High Blood Pressure. During an interview on 03/05/24 11:32 am, with Resident 58, stated, There is not enough food, and the food is only so-so (taste). 14.A review of Resident 33's medical record indicated that resident 33 was admitted on [DATE] with diagnoses that included, Vascular Dementia (Damaged blood vessels in the brain impairing the blood flow to the brain resulting in brain damage and causing memory, reasoning, and thought process problems), Generalized Muscle Weakness, Chronic Pain Syndrome. During an interview on 03/05/24 11:55 am, with Resident 33, stated, Food is horrible. Slop. They cannot even cook a grilled cheese. 15.A review of Resident 56's medical record indicated that resident 56 was admitted on [DATE] with diagnoses that included, Diabetes Mellitus, High Blood Pressure, Benign Prostatic Hyperplasia (BPH, Age related condition where the prostate becomes enlarged. The prostate is a small gland that helps make semen, found below the bladder, the enlargement results in blocking the flow of urine out of the bladder). During an interview on 03/05/24 12:10 pm, with Resident 56, stated, In morning, breakfast, especially eggs, almost always cold. 16.A review of Resident 4's medical record indicated that resident 4 was admitted on [DATE] with diagnoses that included, Acute Pyelonephritis (Bacterial infection causing inflammation to the kidneys), High Blood Pressure, Mixed Hyperlipidemia (condition with high levels of fats in the blood, low density (LDL) cholesterol and triglycerides, which increase the risk of heart disease). During an interview on 03/05/24 12:40 pm, with Resident 4, stated, There is not enough food. It tastes ok sometimes. 17.A review of Resident 59's medical record indicated that resident 59 was admitted on [DATE] with diagnoses that included, Dementia (Entails a decline in mental function from a previously higher 555776 Page 4 of 6 555776 03/08/2024 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some level severe enough to interfere with daily living), Transient Ischemic Attack (TIA, Brief blockage of blood flow to the brain resulting in stroke like symptoms), Presence of Cardiac Pacemaker (Small battery powered device implanted under the skin near the collarbone that prevents the heart from beating too slow). During an interview on 03/05/24 1:55 pm, with Resident 59, stated, Food is cold, didn't know there were alternatives, I was taught to eat what I was given. 18.A review of Resident 6's medical record indicated that resident 6 was admitted on [DATE] with diagnoses that included, Acute Myocardial Infarction (MI, heart attack), Hemiplegia and Hemiparesis following Cerebral Infarction, High blood pressure. During an interview on 03/06/24 2:00 pm, with Resident 6, stated, Scrambled eggs every morning. I do not like it. Food is always cold and does not taste good. 19.A review of Resident 5's medical record indicated that resident 5 was admitted on [DATE] with diagnoses that included, Epilepsy (Disorder of the brain causing recurrent seizures, brief episodes of involuntary movement that may involve a part of the body (partial), or the entire body (generalized), and are sometimes accompanied by loss of consciousness and loss of bladder/ bowel control), Liver Cancer, Parkinson's Disease (Progressive disorder of the central nervous system, causing nerve cell damage, affecting movement, often including tremors). During an interview on 3/6/24 at 09:19 am, with Resident 5, stated, Food is not so good (taste), the food temp is mostly cold. 20.A review of Resident 32's medical record indicated that resident 32 was admitted on [DATE] with diagnoses that included, A fib, Heart Failure, High Blood Pressure. During an interview on 03/06/24 1:15 pm, with Resident 32, stated, Food is not good, no taste. It is cold, especially the scrambled eggs. 21.A review of Resident 18's medical record indicated that resident 18 was admitted on [DATE] with diagnoses that included, Cerebral infarction (stroke, disruption of blood flow to the brain due to problems with the blood vessels that supply it), Malignant Neoplasm of Left Breast (breast cancer), Heart Failure. During an interview on 03/06/24 1:15 pm, with Resident 18, stated, Food is unrecognizable, can't tell what it is. Taste is tolerable, but not great. 22.A review of Resident 9's medical record indicated that resident 9 was admitted on [DATE] with diagnoses that included, High Blood Pressure, Unspecified Severe Protein Calorie Malnutrition, Cellulitis of the Buttock (Bacterial skin infection resulting in inflammation and pain). During an interview on 03/06/24 1:15 pm, with Resident 9, stated, The food has no taste. It is cold, especially the breakfast and scrambled eggs. 23.A review of Resident 22's medical record indicated that resident 22 was admitted on [DATE] with diagnoses that included, Cirrhosis of the Liver (Permanent scarring that damages the liver and interferes with the function), Hypotension (Low blood pressure), Spinal Stenosis (Narrowing of one or 555776 Page 5 of 6 555776 03/08/2024 Gridley Post Acute 246 Spruce Street Gridley, CA 95948

F 0804 more spaces within the spinal canal). Level of Harm - Minimal harm or potential for actual harm During an interview on 03/06/24 8:25 am, with Resident 22 stated, I do not like the food at all (taste/presentation). Residents Affected - Some During a review of Resident Council Minutes, Resident Council Discussion of New Business, and Resident Council Action Form, dated December 2023 through January 2024, the Resident Council Minutes, Resident Council Discussion of New Business, and Resident Council Action Form, indicated, food could be better, (food had) no taste, food was not at desirable temperatures, residents dislike some meals and wanted changes. During an interview on 3/7/24 3:00 pm, with DM, DM stated, I know we have complaints .We are looking at what we can do to try and alleviate this issue and make food more acceptable to our residents. During an interview on 03/08/24 11:12 am, with Admin, Admin stated, I expect the food served to the residents be edible, appetizing, aesthetically pleasing, nutritious, with an appropriate temperature, and to their satisfaction. 555776 Page 6 of 6