Auburn Ravine Terrace

F-F805), and safe food handling and sanitation (cross reference

F-F812), which lacked the benefit of a qualified DS responsible for the day-to-day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of

the expertise of the RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DS by the RD, when the job description and the contract of the RD was essentially based on clinical nutrition.

There was a total of 53 out of 55 residents receiving meals from the facility kitchen.

Findings:

During the annual recertifications survey from 7/16/24 to 7/19/24, multiple issues surrounding the delivery of dietetic services were identified:

1. Meal distribution accuracy - the menu/spreadsheet (a tool helps the kitchen staff to identify food items, portion sizes and utensils (such as scoops, ladles, etc.) for different therapeutic diets) were not followed, and

the portion size of food items were not served correctly;

2. Puree food texture was not prepared appropriately to meet residents' needs, and

3. Safe food handling and sanitation:

a. Cooked chicken leftovers were found without temperature monitoring before being stored in the refrigerator for the cool down procedure;

b .A cook did not practice ambient (room temperature) food cool down procedures when preparing ambient foods (such as tuna salad, egg salad, chicken salad, etc.);

c. Bags of bread (English muffins and raisin bread) passed the used-by date were not discarded;

d. Several sizes metal pans were found stacked wet, and few metal pans with brown and white substances

on the food contact surfaces were stored at the clean and ready-to-use storage areas;

e. The interior of the microwave was found dirty with food debris and liquid splashes;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0801 f. Several cutting boards were found with deep gouges, black substances and strong rancid odor;

Level of Harm - Minimal harm or g. Employee's personal beverage containers were found at the resident's food/beverage preparation area, potential for actual harm and

Residents Affected - Many h. The ice machines located in the kitchen and nourishment room (at nurse station) were not clean.

During an initial kitchen tour and concurrent interview with the Dietary Supervisor (DS) on 7/16/24, at 9:13 a. m., the DS stated she started the position since in September last year (2023). She stated she was not certified as a Dietary Services Supervisor (DSS) or Certified Dietary Manager (CDM), and she added she was still taking courses to be a CDM. She stated there were two Registered Dietitians (RD) contracted to the facility and they visited the facility around 16 hours per week. The DS stated the RDs were responsible for clinical and monthly kitchen sanitation audit, but no in-services for the kitchen staff. She stated she was responsible for the in-services for the staff, but she only did one so far since she started working in the facility.

During an interview with the Regional Operations Director (ROD) on 7/17/24, at 2:14 p.m., he was aware the DS was not qualified for the current position. A concurrent review of the federal regulations with the ROD indicated the qualified personnel for the Dietary Manager position should meet one of the criteria from the state standards, Health and Safety Code 1265.4. The ROD acknowledged the requirements after he reviewed the state standards.

During an interview with the RD on 7/17/24, at 2:45 p.m., she stated she and the other dietitian visited the facility twice per week (around 16 hours per week) per contract. She stated she and the other dietitian were majorly responsible for clinical work (such as nutrition assessments, monitoring resident's weight and attending weight meeting, and consultations) and monthly kitchen sanitation audit. She stated she usually spent one to two hours for the kitchen sanitation audit monthly. She stated she did some meal tray monitoring and in-services for the staff last year but did not do any this year. She stated she spent approximately 80 percent of her visit time for clinical and 20 percent for foodservice operation (kitchen).

During a follow up interview with the RD on 7/18/24, at 10:30 a.m., she stated she was not aware the DS was not qualified for the position and did not meet the state standards. She stated she was aware that the DS still taking the courses to be CDM certified. RD stated she and the other dietitian covered the full-time position due to the previous dietary supervisor not being qualified. She stated the dietitians' hours cut back to part time since the new company took over and the new supervisor, DS, was on board for the position.

A review of the DS's employee file indicated the DS was hired by the facility on 3/22/24 for the full-time position as Dietary Manager. The file indicated DS had three associate degrees with management, business management and recreational management but no indication of any type of professional registration nor certification. The file included ServSafe certification (a certification provided after the completion of training and an examination of the knowledge of safe food handling), but this certification was not one of the requirements of the state standards.

A review of DS's job description (JD) provided by the facility, revised 6/2020, it did not indicate any education and experience requirements for the dietary supervisor position.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0801 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 Level of Harm - Minimal harm or completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. potential for actual harm

A review of the RD's JD, revised 11/2017, it indicated the RD majorly was responsible for clinical work for the Residents Affected - Many facility.

A review of the facility-RD contract titled, [Consulting Company Name] - Consulting Agreement, contracted started 4/1/2024, it indicated the scope of the RD's duties as consultant basis and responsible for clinical work for the facility. It also indicated the RD or RDs were contracted to work in the facility and did not exceed

a maximum of 20 hours per week. The contract also indicated work days and hours were flexible and allowed the RD or RDs to be complete remotely for documentation and charting through the electronic medical record system 50 percent of the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0803 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. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49821

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the menu was followed for

the therapeutic diets (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meal on 7/17/2024 when:

1. 44 out of 44 residents with regular portion size received two scoops (eight ounces (oz.) instead of three scoops (12 oz.) of pasta entree,

2. Five residents (Resident 6, 9, 14, 33, and 49) with pureed texture diets (diet with modified food texture that is smooth and lump-free for people with swallowing and/or chewing difficulties) received pureed garlic bread sticks instead of soaked white dinner rolls,

3. 16 residents (Resident 7, 11, 19, 21, 25, 29, 32, 38, 39, 40, 43, 46, 52, 56, 110, and 261) who were on Level 5 Minced and Moist texture diets (modified texture diet for people with swallowing and/or chewing difficulties), Heart Healthy/Cardiac diets (diet with reduced amount of fat, cholesterol, and sodium for people who are at risk of heart diseases or have heart diseases), and/or Renal diets (diet for people with chronic kidney disease) received wheat dinner rolls instead of white dinner rolls,

4. Five residents (Resident 2, 4, 29, 36, and 52) with small portion diets (diet with controlled serving size is smaller for less calories or sometimes for person's preference) were not served with the correct measured serving size because the menu spreadsheet did not include small portions for accurate measurement.

These failures had the potential to result in compromising the medical and nutritional status of 50 residents for a census of 55.

Findings:

1. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that 44 residents who were on the regular portion size diets received two scoops equaling 8 oz. (2 servings of a 4-oz. scoop equals 1 cup) instead of three scoops equaling 12 oz. (equals 1 1/2 cups) of pasta entree.

A concurrent review of the facility document entitled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated July 2024, it showed, 1 1/2 cups (12 oz.) of pasta dish for all regular portion diets, including for Regular, IDDSI (International Dysphagia Diet Standardization Initiative, describes texture modified foods and thickened liquids used in care settings) Level 5: Minced and Moist, Pureed, Consistent Carbohydrate (diet to control blood sugar level that is intended for people with diabetes), Heart Healthy/Cardiac, and/or Renal diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0803 During an interview with the Dietary Supervisor (DS) on 7/17/24, at 12:38 p.m., the DS acknowledged that residents with regular sized portions received two scoops (8 oz.) of the pasta dish for lunch. A concurrent Level of Harm - Minimal harm or review of the Diet Extensions (a spreadsheet with different therapeutic diets residents should receive potential for actual harm according to planned food items with specific portion sizes and modified food texture) with the DS, she stated those residents should have received three scoops (12 oz.) of the pasta dish. Residents Affected - Some 2. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that five residents (Resident 6, 9, 14, 33, and 49) with puree texture diets were served a pureed texture garlic bread stick instead of a soaked white dinner roll (for pureed diets, bread items are sometimes soaked in a liquid such as milk to soften their texture).

A concurrent review of the facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it indicated residents with pureed texture diets should receive a soaked white dinner roll.

During an interview with the DS on 7/17/24, at 12:38 p.m., the DS acknowledged that residents with pureed texture diets received pureed garlic bread sticks. After reviewing the Diet Extension, she stated those residents should have received the soaked white roll.

3. During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that 16 residents (Resident 7, 11, 19, 21, 25, 29, 32, 38, 39, 40, 43, 46, 52, 56, 110, and 261 ) who were on the IDDSI Level 5 Minced and Moist texture diet, Heart Healthy/Cardiac diet, and/or Renal diet received wheat dinner rolls instead of white dinner rolls.

A concurrent review of the facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it indicated a white dinner roll was to be served for the following diets: IDDSI Level 5 Minced and Moist texture diet, Heart Healthy/Cardiac diet, and/or Renal diet.

During an interview with the DS on 7/17/24, at 12:38 p.m. she acknowledged that those residents with Level 5 Minced and Moist texture diets, Renal diet, and/or Heart Healthy/Cardiac diet received a wheat roll. After reviewing the Diet Extensions, she confirmed they should have received a white roll.

4. During an interview with the DS regarding the small portion on the Diet Extension on 7/16/24, at 9:05 a.m.,

the DS stated small portion sizes were not listed on the current menu system with the current menu company

the facility was using. The previous menu company the facility used did include portion sizes for small meals

on their menu/spreadsheets. The DS stated she has instructed the [NAME] and kitchen staff to give one-half amount of the regular diet for small portions. She confirmed the small portion did not have accurate measurements since the serving sizes and tools were not included on the menu/spreadsheet.

During an observation of lunch service on 7/17/24, beginning at 11:30 a.m., it was noted that five residents (Resident 2, 4, 29, 36, and 52) with small portion diets were not served an accurate measured portion because the Diet Extensions did not include precise measurements for small portion size diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0803 During a follow up interview with the DS on 7/17/24, at 12:38 p.m., she acknowledged that those residents with small portions received one scoop (4 oz.) of pasta. She again confirmed that no portion measurements Level of Harm - Minimal harm or had been allotted on today's menu for small portion size diets and the portion amounts were discussed with potential for actual harm the [NAME] and kitchen staff, and the measurement was up to the Cook's discretion.

Residents Affected - Some During an interview with the Registered Dietician (RD) on 7/18/24, at 10:30 a.m., she stated the current menu company did not have the portion size for diets in the menus. She stated this problem needed to be fixed right away because it could affect residents who are being monitored for weight loss. She stated they were looking for a new menu company and the menu should include portion sizes with accurate measurements.

A review of facility document titled, Diet Extensions: Wednesday, Week 2, [NAME] Ravine- Spring/Summer, dated 7/2024, it did not indicate serving sizes (such as ounces, cups, etc.) for small portion diets.

A review of facility document titled Job Description-Cook, Department: Dietary, revised 9/1/23, it showed, . Essential Job Functions: Follow recipes and prepare foods that correspond to menu cycles and recipes prepared by Dietician .

A review of facility document titled, Dietary Aide-Job Duties and Responsibilities, revised 6/2020, it showed, . Food Services: Assist in checking diet trays before distribution .

A review of facility policy and procedure titled, Menus, revised 10/2017, it showed, .Menus are developed and prepared to meet resident .needs while following established national guidelines for nutritional adequacy .Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of

the Food and Nutritional Board (National Research Council and National Academy of Sciences) .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 49821

Residents Affected - Some The facility failed to ensure the appropriate food texture for five residents (Resident 6, 9, 14, 33, and 49) who were on a puree texture diet and received pureed ziti with cheese with chunks of pasta and tomato. The total census was 55.

This deficient practice had the potential to increase risk to the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway).

Findings:

A concurrent observation and interview on 7/17/24, at 10:27 a.m. with [NAME] (C)1 were conducted during puree preparation for the lunch meal. C1 stated the texture for the puree pasta (ziti with cheese) should be smooth, like mashed potatoes.

A concurrent observation and interview on 7/17/24, at 12:38 p.m., with the Dietary Supervisor (DS), were conducted during food sampling of the puree pasta for the test meal tray. The texture of the puree pasta and cheese entree had a bulky, lumpy consistency when sampling. After tasting, the DS stated the pureed pasta texture was lumpy with noticeable chunks of pasta and tomato, and stated the texture was not correct. The DS stated the texture should have been a smooth consistency. She added that residents who have swallowing difficulties might have increased risk for choking on the food chunks.

During an interview with the Registered Dietician (RD) on 7/18/24, at 10:30 a.m., she stated, I was very disappointed with yesterday's puree. I was very surprised because normally they do a very good with the purees. The RD disclosed she observed the puree pasta ziti with cheese when she performed dining

observation on 7/17/24 lunch meal. She acknowledged the puree ziti with cheese had lumps and stated the kitchen staff and the cook needed more training for that issue.

A review of the facility's pureed pasta procedure titled PU4 Pasta Ziti Baked with Cheese [2] (PU4 Baked Ziti with Cheese), dated 5/2024, it showed, Blend [in food processor] until smooth .Final product must not be sticky or gummy. Pureed foods are classified as Level 4 as established by the IDDSI Framework (International Dysphagia Diet Standardization Initiative, describes texture modified foods and thickened liquids for care settings).

A review of a facility document titled [Company name] Menu Solutions: Standards of Professional Practice-Diet Guide, updated 3/19/2021, under the section of IDDSI Level 4: Pureed Food indicated, . Description - This diet is used in the dietary management of dysphagia with food texture modification described as foods that are smooth and lump-free, not firm or sticky .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49821

Residents Affected - Many Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:

1) Cool down process was not performed for meat leftovers (any food that was prepared for service but was not served),

2) Procedure for cooling down method for ambient (room temperature) food was not being followed,

3) Metal serving pans had brown and white substances on the inside surface; serving pans were found stacked wet,

4) Expired bread had not been discarded,

5) Microwave had food debris on upper interior surface,

6) Several cutting boards had gouges, black smudges, and rancid odor,

7) Employees' beverage containers were stored in residents' food and drink preparation area, and

8) Ice machines in kitchen and nourishment rooms were not clean.

These failures had the potential to lead to foodborne illness for a total of 53 out of 55 residents who received facility prepared foods.

Findings:

1. During an inspection in the walk-in refrigerator on [DATE REDACTED], at 10:28 a.m., a bucket of cooked leftover chicken breasts (cooked on [DATE REDACTED]) was found that did not have temperature monitoring and without the cool down process done before being stored in the refrigerator.

In a concurrent interview with the Dietary Supervisor (DS), she reviewed the weekly menu for the week and stated the chicken was prepared for the Asian Chicken salad for dinner on [DATE REDACTED]. When the DS was asked whether the cook performed a cool down process for the chicken pieces, she reviewed the Food Cooling Log and stated there was no entry for the chicken breasts for [DATE REDACTED]. She stated the cook who placed the chicken breasts in the refrigerator would return to work on [DATE REDACTED].

During a follow up interview on [DATE REDACTED], at 9:05 a.m. with the DS, she stated [NAME] (C) 2 was the one who cooked the chicken in the walk-in refrigerator, and he would be in to work that morning at 10:30 a.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 During an interview with C 2 on [DATE REDACTED], at 10:54 a.m., he stated someone else cooked the chicken breasts, but he was the one who put them in the refrigerator that evening ([DATE REDACTED]) without taking the temperature of Level of Harm - Minimal harm or the chicken or following the cool down process. He stated, It was a mistake, and specified that because he potential for actual harm didn't perform the cooling down method, he wouldn't know whether the temperature of the food was within safe food parameters. Residents Affected - Many

During an interview with the Registered Dietitian (RD) on [DATE REDACTED], at 10:30 a.m., she stated the cook should have done the cool down procedure for the leftovers before storing them in the refrigerator for food safety.

She said, We need to do the in-service, and we need to get a log for the process.

A review of facility's Food Preparation and Service, revised Nov. 2022, it showed, .Potentially hazardous food (PHF) including meats, poultry .Rapid Cooling: PHF are cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit (F) to 70 F within two hours and then to a temperature of 41 F or below within the next 4 hours. The total cooling time between 135 F and 41 F is not to exceed 6 hours .

A review of facility policy and procedure titled, Use of Leftovers (2013), it showed, Leftovers must be cooled to 70 F within 2 hours and then down to 41 F within another 4 hours .

2. During a concurrent observation and interview on [DATE REDACTED] at 3:55 p.m., C 2 was preparing chicken salad for the evening meal, chicken salad sandwiches. C 2 stated there was no system for cooling ambient foods, nor was he practicing it. He verbalized the process of ambient food (such as tuna or egg salad) cool down with prompting. He stated he would put the made salads in the refrigerator but not take any temperature nor using the cool down log for monitoring. C 2 also stated he never practiced or had been told to do the ambient food temperature monitoring and cool down process.

During an interview with the DS on [DATE REDACTED], at 2:55 p.m., she stated the kitchen did not have a policy and procedure for ambient foods, and the kitchen staff were not practicing the ambient cool down process.

During a follow up interview with the DS on [DATE REDACTED], at 9:12 a.m., she changed her answer and stated the kitchen had a cool down process for ambient foods. However, she stated the staff were not monitoring the temperature after the cold salads were prepared. She confirmed that the staff should be monitoring the temperature and practicing the ambient food cooling down process.

A review of undated facility's policy and procedure titled, Addendum to Food Preparation, it showed, Ambient food being used for cold food preparation will be pulled from the shelf 24 hours in advance and placed in the refrigerator. Once pulled from the refrigerator, and opened, food items will be temped [temperature taken] to assure temperatures are 41 degrees or below. Once the preparation of the food is completed, the item will then be temped again to assure food temperature has not exceeded 41 degrees .Ambient food prepared using ingredients from room temperature items for cold production must be cooled to 41 degrees within four hours .Will maintain cooling logs for ambient food.

3. During a concurrent observation and interview on [DATE REDACTED], at 9:53 a.m. and 10:12 a.m.,

there were several metal pans found having issues stored in the clean and ready-to-use areas as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 -9 of ,d+[DATE REDACTED] sheet pans (stacked wet)

Level of Harm - Minimal harm or -3 of ,d+[DATE REDACTED] sheet pans (stacked wet) potential for actual harm -4 of full sheet pans (stacked wet) Residents Affected - Many -2 of full sheet pans (had brown and white substances on the inside surfaces)

The Assistant Dietary Supervisor (ADS) stated the pans should be dried. She also stated the pans should be clean and the staff should check them before being stored away.

During an interview with the RD on [DATE REDACTED], at 10:30 a.m., she stated the pans should be fully dried and clean before being stored away. The RD stated she would talk with the dishwasher about completely air drying the pans.

A review of facility's policy and procedure titled, Sanitation: Dish Machine Usage and Testing, dated [DATE REDACTED],

it showed, .Air dry: Place equipment or utensils onto a clean surface to air dry. Do not dry with a towel or other method .Return to storage: Once equipment and utensils are completely air dried, they can be returned to

storage .

A review of the facility's policy and procedure titled, Sanitation, dated ,d+[DATE REDACTED], it indicated all food contact surfaces and utensils must be washed to remove the soil completely before manual or machine wash, then sanitized.

4. During a concurrent observation and interview on [DATE REDACTED], at 10:18 a.m., there was a tray of four bags of English Muffins with a label written, Pulled [DATE REDACTED], Use by [DATE REDACTED]. There was another tray of three bags of raisin bread with a label written, Pulled [DATE REDACTED], Use by [DATE REDACTED]. The ADS confirmed and stated those breads were past the use by date and should be discarded. She added the breads stored in the freezer are pulled out for thawing at room temperature. She stated it was everybody's responsibility to check the bread.

During an interview on [DATE REDACTED], at 9:05 a.m. with the DS, she stated the bread was received frozen from the supplier and kept in the walk-in freezer. She stated the kitchen followed the dry storage guidelines for the bread, which could keep for five to seven days unopened or opened on the shelf. A concurrent review of facility policy and procedure, Food Receiving and Storage Policy and Procedure, dated ,d+[DATE REDACTED], with the DS, under the Refrigerated/Frozen Storage section, which stated that refrigerated foods should be eaten by their 'use by' date, or else need to be frozen or discarded. The DS confirmed that she would follow that section of the guidance for the dry foods which would be discarded if past the use by date.

During an interview with the RD on [DATE REDACTED], at 10:30 a.m., she stated the kitchen staff need more training.

She stated she planned to talk to the staff more about putting correct dates on labels. The RD stated, There's no excuse. They shouldn't have them (expired bread items) there. She stated she had a prior discussion with kitchen staff about doing a daily walkthrough of food items and discarding expired food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 A review of facility's document titled, Dry Goods Storage Guidelines, dated 2023, it indicated that the bread should be stored, ,d+[DATE REDACTED] days unopened on shelf XXX,d+[DATE REDACTED] days opened on shelf .This storage Level of Harm - Minimal harm or length is to be followed unless you have manufacturer's recommendation indicating otherwise. potential for actual harm

A review of facility policy and procedure titled, Food Receiving and Storage, revised Nov. 2022, it showed, . Residents Affected - Many Refrigerated/Frozen Storage: Refrigerated foods are labeled, dated and monitored so they are used by their 'use by' date, frozen or discarded . (The DS stated this guidance also applied to the dry food, which needed to be discarded when past the use-by date.)

5. An observation of the microwave oven cleanliness and concurrent interview was conducted on [DATE REDACTED], at 10:09 a.m. The interior top portion of the microwave was found with food residue and liquid splash spots. Dietary Aide (DA) 1 confirmed and stated the microwave was dirty and that she cleans the oven every day.

She stated the microwave was scheduled to be cleaned daily.

During an interview with the RD on [DATE REDACTED], at 10:30 a.m., she acknowledged and agreed the microwave should be cleaned daily.

A review of facility's policy and procedure titled, Sanitization, revised ,d+[DATE REDACTED], it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair .

6. A concurrent observation of the cleanliness of cutting boards and interview was conducted with the ADS

on [DATE REDACTED], at 9:24 a.m. There were seven plastic cutting boards found with deep gouges, dark brownish black splotches on the surfaces, and a rancid odor. The ADS confirmed and stated the cutting boards were

in bad condition and agreed they smelled. She also stated she would discard them.

During an interview with the RD on [DATE REDACTED], at 10:30 a.m., she stated she was aware of the issues with the cutting boards. She stated she recommended they do a chorine wash, and she had also instructed the staff to discard marred or stained cutting boards. She stated the cutting boards should have smooth surfaces to be easily cleaned.

A review of the facility's policy and procedure titled, Sanitization, revised ,d+[DATE REDACTED], it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/chemical sanitizing solutions .Cutting boards (acrylic or hardwood) will be washed and sanitized between uses .

7. During an initial kitchen tour on [DATE REDACTED], at 9:00 a.m., an observation of the food preparation area and

interview was conducted with the ASD. There were personal beverage containers found on the resident's food and drink preparation area. The ASD confirmed the beverage containers belonged to the kitchen staff.

She stated there was no designated area for the staff's drink containers. In a follow up interview with the DS at 9:20 a.m., she confirmed that staff's drinks were in the food preparation area and agreed there should be

a designated area for staff's belongings.

During an interview with the RD on [DATE REDACTED], at 10:30 a.m., she stated staff's personal items and drinks were not allowed in the food/beverage prep area and these items should be in a designated area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 A review of the undated facility's policy and procedure titled, Employee Health and Hygiene: Personal Items, Food and Drink, it showed, .Designate area within the facility for associates to store beverages-ideally 3 feet Level of Harm - Minimal harm or from any food preparation or storage area. Beverages should not be stored in and around cook areas or potential for actual harm utility rooms .Observe food preparation areas to ensure no food, drink .are stored outside of their designated area . Residents Affected - Many 8. During an inspection of the ice machine in the kitchen on [DATE REDACTED], at 11:20 a.m., the Dietary Aide (DA) 2 stated he was responsible for the monthly cleaning and sanitizing for the ice storage bin. He dissembled the top part (machinery part) of the ice machine. DA 2 stated he was also responsible for rinsing the water curtain (a plastic cover rest on the ice making panel of the top machinery component, the function is to prevent ice shooting out and redirect the ice to the ice storage bin) and the water trough (a component that holds the water before it is frozen during the ice making process) with hot water only. He stated he did not touch anything else other than the ice storage bin, water curtain and water trough.

During an interview with the Maintenance Supervisor (MS) on [DATE REDACTED], at 11:40 a.m., he stated that the facility hired outside vendor and sent their technician to the facility and performed the deep clean (clean and sanitize the machinery part (top part) of the machine and the ice storage bin with the chemical solutions) of

the ice machine every six months. Upon removing the ice machine's top access panel, the water curtain and

the water trough, there were pink and slimy substances found. This was covering some portion outside of the water curtain and inside of the water trough and was easily removed when wiping with paper towel. There were significant black substances found at the bottom of the evaporator unit (a part where the water condenses and makes ice) and was easily wiped off with the paper towel. The MS stated the last deep clean was done on [DATE REDACTED] and the water filter would be changed every year with the last change on [DATE REDACTED]. The MS confirmed the pink and black substances and stated maybe the ice machine was not scrubbed enough.

During an inspection of the ice machine in the nourishment room located at the nurse station on [DATE REDACTED], at 11:43 a.m., the MS stated he was responsible to clean the ice storage bin and rinse the water curtain and water trough with hot water and clean the ice dispenser nostril monthly. When the MS removed the top access of the machinery part of the ice machine, there were pink slimy substances found on the water curtain and inside the water trough, and on the top and bottom rims of the ice making panel. The pink slimy substances were easily wiped off with paper towel. In addition, there were significant black substances found

on the bottom of the evaporator unit and the black substances were easily wiped of with paper towel and felt

the surface was not smooth when touched. The MS stated the outside vendor was responsible to do deep clean for the ice machine every six months and the last service was done on [DATE REDACTED]. The MS confirmed the pink and black substances were found and stated maybe the outside vendor technician did not scrub enough when cleaning the ice machine.

During an interview with the outside vender technician (OVT) on [DATE REDACTED], at 3:35 p.m., he stated the previous technician may not be scrubbing the parts of the ice machine enough and the calcium deposits accumulated for both ice machines (kitchen and nourishment room). He stated the calcium deposits took times to be soften and clean better.

During an interview with the Registered Dietitian (RD) on [DATE REDACTED], at 10:30 a.m., she stated the ice machine should be clean. She stated she checked the ice machine monthly during the monthly kitchen sanitation audit, but she did not check the top (machinery) part.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 A review of the facility policy and procedure titled, Sanitization, revised [DATE REDACTED], indicated, The food service area shall be maintained in a clean and sanitary manner . ice machine and ice storage containers will be Level of Harm - Minimal harm or drained, cleaned and sanitizer per manufacturer's instructions . potential for actual harm

A review of the undated kitchen ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Residents Affected - Many Operation and Maintenance Manual, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. CLEANING/SANITIZING PROCEDURE This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized . Removes 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 undated nourishment room ice machine manual titled, [Manufacturer's brand] Dispensers Installation, Use & Care Manual, indicated all removable and disassembled parts of the ice machine should be clean and sanitize with the cleaning and sanitizing solutions monthly.

According to 2022 FDA (Food and Drug Administration) Food Code, on section ,d+[DATE REDACTED].11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae).

In addition, on Section ,d+[DATE REDACTED].11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 48140 potential for actual harm Based on observation, interview, and record review the facility failed to ensure safe food handling and Residents Affected - Few storage for food brought in by family for one resident (Resident 2) out of 15 sampled residents.

This failure had the potential for Resident 2 to experience foodborne dangers, such as, nausea, vomiting and diarrhea by consuming moldy food.

Findings:

A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe).

During a concurrent observation and interview on 7/16/24 at 9:31 a.m. with Resident 2, in Resident 2's room,

a transparent plastic container with a red plastic lid was observed on Resident 2's bedside table. Indistinguishable personal food items with greenish-blue spots and fuzzy growth were observed through the container. Resident 2 stated, I'm not sure what those are, my family brought me that a while ago.

During a concurrent observation and interview on 7/16/24 at 9:36 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 2's room, the CNA 1 opened the plastic container and confirmed the contents in the container was, old food with fuzzy mold. The CNA 1 stated, [Resident 2] could've been really sick if she had eaten that. The CNA 1 received permission from Resident 2 to discard the food and plastic container.

During a concurrent observation and interview on 7/18/24 at 2:33 p.m. with DON (Director of Nursing) a photo of Resident 2's plastic container with personal food items inside was shown to the DON. The DON confirmed the personal food items, looks moldy. The DON stated, Personal food items brought in by family should have the resident's name, date, and time on the container. The food item will be refrigerated for 24 hours and then it will get thrown away. Items left out at room temperature should be thrown away after two hours.

During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised March 2022, indicated, Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date .The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 49821 potential for actual harm Based on observation and interview, the facility failed to provide a clean environment for the residents and Residents Affected - Many visitors when one of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids.

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 7/16/24, at 10:52 a.m., it was observed one out of one outside dumpster was covered with its two lids. However, the dumpster lids were bowed away from the midline where they converged, leaving a two-inch gap in between. The deformed lids lacked the integrity to securely cover the bin. The Dietary Supervisor (DS) confirmed the condition of the dumpster lids and agreed that either the lids needed to be fixed or the facility needed a new trash bin.

During an interview with the Director of Clinical Operations (DCO) on 7/19/24, at 9:35 a.m., she stated the facility did not have a policy and procedure regarding dumpster conditions. The DCO stated the maintenance department called a waste management company and had to purchase new lids for the dumpsters.

According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, referenced 7/23/24, (A) Receptacles and waste handling units for refuse .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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0839 Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47563 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure one Certified Nursing Residents Affected - Many Assistant (CNA), CNA 2, of five sampled CNAs had a valid CNA license.

This failure had the potential to result in all 55 residents in the facility to receive care from an unqualified person.

Findings:

During a concurrent interview and record review on [DATE REDACTED] at 11:44 a.m. with the Director of Nursing (DON),

the CNA 2's license verification was reviewed. The DON confirmed CNA 2's license verification indicated an expiration date on [DATE REDACTED]. The DON stated she expected CNAs who worked at the facility to have a valid CNA license.

During a concurrent observation and interview on [DATE REDACTED] at 11:48 a.m. with the Director of Staff Development (DSD) in the facility's dining room, CNA 2 was assisting residents with their lunch meal. The DSD stated she was aware CNA 2's license was getting close to expiration, CNA 2 had not yet submitted an updated CNA license and confirmed CNA 2 was currently working a CNA shift.

An interview on [DATE REDACTED] at 11:53 a.m., CNA 2 confirmed she has not received a CNA license renewal yet and her CNA license was expired.

A review of the facility's policy and procedure titled Competency of Nursing Staff revised [DATE REDACTED], indicated, . all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law .

A review of California Health and Safety Code, Division 2. Licensing Provisions, Chapter 2. Health Facilities Article 9, Section 1337.6, effective date [DATE REDACTED], indicated, .The department shall give written notice to a certificate holder 90 days in advance of the renewal date and, 90 days in advance of the expiration of the fourth year that a renewal application has not been submitted, and shall give written notice informing the certificate holder, in general terms, of the provisions of this article. Nonreceipt of the renewal notice does not relieve the certificate holder of the obligation to make a timely renewal. Failure to make a timely renewal shall result in expiration of the certificate

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34328 potential for actual harm Based on interview, and record review the facility failed to maintain an infection control program for a census Residents Affected - Many of 55 residents when:

1. Facility staff were observed not performing hand sanitation when entering and exiting resident's rooms;

2. Soiled linens were processed without adequate use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses); and,

3. The washing machine's water temperature was not monitored.

These failures decreased the facility's potential to prevent the spread of disease and infections among residents.

Findings:

1. During an observation and concurrent interview with Environmental Service 1 (EVS 1) on 7/18/24 10:32 a. m., the EVS 1 was observed entering and exiting resident rooms 24, 25, 12, and 13 without performing hand sanitation. The EVS 1 was observed to push her cart near room [ROOM NUMBER], entered room [ROOM NUMBER] with gloved hands without sanitizing her hands. The EVS 1 was observed to exit room [ROOM NUMBER], removed her gloves, and donned a new pair of disposable gloves without sanitizing her hands with the intention of entering room [ROOM NUMBER]. The EVS 1 confirmed she had been trained in handwashing and hand sanitation practices, but was rushing and trying to save time to complete her work.

During an observation and concurrent interview on 7/18/24 at 11:05 a.m., the EVS 2 was observed to exit room [ROOM NUMBER] holding towels with ungloved hands. The EVS 2 proceeded to open the lid of the hamper with her bare hands and tossed the dirty towels into the linen hamper. The EVS 2 immediately re-entered room [ROOM NUMBER] without sanitizing her hands. The EVS 2 then touched the resident's clean blanket and began to rearrange it. The EVS 2 stated the towels were from the patient's bathroom sink

in and confirmed the towels were dirty and needed to be placed in the dirty laundry hamper. The EVS 2 she confirmed she should have worn gloves. The EVS 2 stated she was in a hurry. The EVS 2 also confirmed

she should have washed her hands before going into the resident's room and tidying up the resident's blanket.

During an observation and concurrent interview on 7/18/24 11:20 a.m., the Certified Nursing Assistant 3 (CNA 3) was observed to enter and exit rooms [ROOM NUMBER] without using any of the alcohol-based hand sanitizers located throughout the hallway to sanitize her hands. The CNA 3 confirmed she had not sanitized her hands and should have done so before entering the residents' rooms.

During an observation on 7/18/24 at 11:25 a.m. resident rooms [ROOM NUMBER] were observed to have faucets and sinks with soap dispensers available for use to wash hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0880 2. During an inspection of the facility laundry department was performed on 7/19/24 at 9:12 a.m. accompanied by the Infection Preventionist (IP). The laundry department was divided into two sections: one Level of Harm - Minimal harm or room for storage of dirty linens and the other room was for storage of clean linens. The dirty linens section potential for actual harm was observed to have one box of disposable gloves but no other PPE equipment was accessible in the dirty linens room. Residents Affected - Many

During an observation of the clean linens section of the laundry room on 7/19/24 at 9:15 a.m. the Linen Room Technician (LRT) was observed folding clothes and linens. In a concurrent interview the LRT stated

she was folding the washed and clean linens.

The LRT was asked to demonstrate how she processed the dirty linens to be washed. The LRT entered the dirty linens room and stated she donned disposable gloves. The LRT stated she transported the dirty linen hamper into the laundry room and the dirty linens were placed into the washing machines to be washed. The LRT stated she would then remove the disposable gloves from her hands and would sanitize her hands. The LRT confirmed she had never worn a cover gown or faceshield when processing dirty linens, she wore only disposable gloves. The LRT further stated she had not been trained to use a gown or face shield when processing dirty linens.

In an interview with the IP on 7/19/24 at 9:30 a.m., the IP confirmed there were no other PPE in the dirty linens room except for the gloves. Concurrent interview the IP, she stated the LRT staff should be wearing gloves, a gown, and face shield when processing and handling dirty linens.

In a further tour of the clean linen section of the laundry department with the IP and LRT on 7/19/24 at 9:45 a. m., the LRT confirmed there were two washing machines and two dryers in the department. The LRT stated

she did not know if the washing machines or dryers were high or low temperature machines. The LRT further stated she did not knowwhat the water temperatures should be in the the washing machines, nor what the dryer machine temperatures were supposed to be when drying the clothes. The LRT stated she had not been monitoring temperatures for either the washing or dryer machines. The only log she kept was for cleaning the lint screens of the dryers.

The LRT further indicated the washing machines were supplied from a dedicated hot water line. She pointed to a tankless water heater and had a digital readout which indicated 131 degrees Fahrenheit (a unit of measurement that is used to measure temperature). The LRT was not aware of what the minimum temperatures should be when washing the dirty linens.

In an interview with the Maintenance Supervisor (MS) on 7/19/24 at 9:50 a.m., the dryer temperature was checked with a heat gun and indicated 139 degrees Fahrenheit (F). The MS stated he did not know what the optimal temperature range the dryers and the washing machines were supposed to operate within. The MS confirmed he was in charge of the Laundry Department. The MS stated the hot water supply for the washing machines came from a tankless water heater and the temperature reading from a digital thermometer was 131 degrees F. The MS stated he was unaware the temperatures were needed to be monitored on the washing machines and the dryers. There were no other temperature measuring tools to indicate how hot the water temperatures gets with the washing cycles, nor the dryers temperature when in operation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0880 A review of an electronic mail addressed to the MS by the laundry company dated 7/19/24 at 11:46 a.m. indicated, .The washer does not have an internal water heater. However water temps [temperatures] on a Level of Harm - Minimal harm or Hot fill setting should be around 150 degrees F .The dryers are as follows .Low heat temp= 140 degrees, potential for actual harm Medium heat temp= 160 degrees, High heat temp= 185-190 degrees .

Residents Affected - Many A review of the facility policy and procedure titled Laundry and Bedding soiled revised September 2022 indicated, .Soiled laundry/bedding shall be handled, transported and processed according to the best practices for infection prevention and control. Handling .All used laundry is handled as potentially contaminated using standard precautions (e.g. gloves and gowns when sorting .Onsite Laundry Processing . Laundry processed in hot water temperatures is 160 degrees F for 25 minutes.

A review of an undated facility procedure titled Isolation Laundry Procedures indicated, .Procedures .Wear rubber gloves and gown/apron .Set booster water heater according to instructions to highest setting .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34328 potential for actual harm Based on interview and record review the facility failed to develop, implement, and monitor an infection Residents Affected - Many control program with the use of antibiotics when:

1. The Infection Prevention and Control Program (IPCP) failed to monitor the laboratory indications on the use of antibiotics.

2. There were inadequate tracking tools in use for tracking of residents on antibiotics and the indications for

the use of antibiotics

3. There were inadequate infection control inservices for the facility staff on handwashing.

These failures had the potential for residents to be exposed and acquire infectious diseases causing illness.

Findings:

1. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide

the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI) which were rooms 11, 23, 24, 25, 26. The IP was asked how she verified and confirmed the specific residents in rooms 11, 23, 24, 25, 26 who had a UTI. The IP was not able to answer who were the specific residents in the room that had UTI, nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use.

The IP was asked who were the current residents she had that were on antibiotic treatment. The IP state for Resident 35 (3 A), the Medical Doctor (MD) prescribed Ciprofloxacin, an antibiotic for the treatment of UTI.

The IP was asked what was the laboratory indication for the use of the antibiotic, she stated she had not checked for the urinalysis and the C/S indication. She was asked to check the lab of Resident 35 and the culture result dated 7/18/24 result was urogenital flora (normal). Concurrent interview with the Director of Clinical Operations she was was asked to verify the laboratory findings, and she stated it was normal and the resident had no indications for use of the antibiotic. The DCO stated she will clarify with the MD if not to discontinue the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0881 Further interview with the IP on 7/18/24 at 2:55 p.m. the IP was asked to verify if Resident 29 in room [ROOM NUMBER] was on antibiotics. The IP was not aware if resident 29 was on antibiotics. The MD orders Level of Harm - Minimal harm or were reviewed with the IP and she confirmed that Resident 29 was on antibiotic Cephalexin 250 mg potential for actual harm (milligrams, a dosage) by mouth was ordered on 5/31/24. Further interview with the IP she stated the Cephalexin was ordered to be given 1 capsule once a day for Prophylaxis (preventative) related to Urinary Residents Affected - Many Tract infection. The IP was asked to verify if the resident had any urinalysis or culture and sensitivity labs done to indicate the Resident had any UTI. The IP confirmed there were no laboratory examinations ordered. Further interview with the IP the antibiotic Cephalexin was started on 5/31/24 and as of 7/18/24 Resident 29 had been on antibiotics a total of 48 days for the prevention of UTI. Concurrent interview with the DCO she stated the used of Cephalexin antibiotic for UTI prophylaxis was not normal clinical indications for usage. The DCO stated she will clarify with the MD if not discontinue the medication.

2. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide

the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI). The IP was asked how she verified and confirmed the rooms 11, 23, 24, 25, 26 had UTI.

The IP was not able to answer who were the residents in the room that had UTI nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or

a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use.

Concurrent interview with the DCO she stated there were tracking tools for the IP to use in the Electronic Health Records (EHR). The DCO stated it was still in development and not yet active. The DCO confirmed there were no other tools in used for monitoring infections and for the use of antibiotics.

3. During an interview with the IP on 07/18/24 at 2:42 PM The IP was asked about staff infection control in-services specifically hand washing. The IP was made aware of observations made on staff who were not performing hand hygiene when going in and out of residents rooms. The IP stated in-services were done on handwashing, and she confirmed all employees whether they are clinical or non clinical employees are expected to attend handwashing inservices. The IP was asked to provide the staff in-services attendance sheets on handwashing from January 2024 to current date of 7/18 /24. The IP stated that ALL staff must attend handwashing in-services whether they are clinical or non-clinical employees. The IP stated and verified total number of employees were 82. The breakdown were Fulltime employees were 59, Part time were 15, on call were eight (8).

The IP provided the In-service Training attendance on Handwashing and the sign in attendance sheets dated 2/6/24 for in-service times of 6:30 a.m. and 2:10 p.m. total staff who attended were six (6) staff members.

The IP confirmed that was all the inservices she had on file.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0881 Review of some of the Infection Prevention Nurse job description indicated: .Plan, develop, organize, implement evaluate, coordinate, and direct our infection control program in accordance with the current rules, Level of Harm - Minimal harm or regulations, and guidelines that govern such requirement .Interpret infection control policies and procedures potential for actual harm as necessary .Assist the supervisor of laundry services in developing infection control procedures for the handling of clean and soiled laundry and linen, equipment cleaning .Ensure that all nursing service personnel Residents Affected - Many follow established isolation precautions to include standard/universal precautions .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

Level of Harm - Minimal harm or 47563 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by Residents Affected - Few a resident to signal the need for help) was accessible for one of 15 sampled residents (Resident 11).

This failure had the potential to result in unmet resident needs and delayed staff response.

Findings:

A review of Resident 11's admission record, indicated Resident 11 was admitted to the facility in 2016 with diagnoses that included spastic hemiplegia (uncontrolled muscle movements on one side of the body), contracture (permanent tightening of muscles which causes stiffness and prevents normal movement of a body part), polyarthritis (painful inflammation and stiffness affecting five or more joints at the same time), dementia (a loss of memory and problem-solving abilities which interfere with daily life) and a history of falling.

A review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 5/1/24, indicated Resident 11 had moderate memory problems, impairments to both upper body and lower body, and was dependent on staff for mobility and care related to incontinence (unintentional passing of urine and bowel movements).

During a concurrent observation and interview on 7/16/24 at 1:15 p.m. with Resident 11 in Resident's 11 room, Resident 11 was sitting up in a padded chair in her room, leaning and slumped on her left side, with a strong odor of feces coming from resident. Resident's 11 call light was tied to the resident's bed out of reach of Resident 11. Resident 11 had a grimace on her face and stated she needed staff's help but she could not reach her call light to get staff's attention.

During a concurrent observation and interview on 7/16/24 at 1:19 p.m. with Certified Nurse Assistant 2 (CNA 2) in Resident 11's room, CNA 2 confirmed Resident 11 could not reach the call light that was tied to the bed while she was sitting in the chair in her room. CNA 2 acknowledged the call light is supposed to be left in reach of Resident 11 so she can call for assistance.

During a concurrent observation and interview on 7/19/24 at 1:20 p.m. with Licensed Nurse 4 (LN 4) in Resident 11's room, the LN 4 confirmed Resident 11's call light was out of Resident 11's reach and confirmed staff should ensure call light is in reach of Resident 11 so she could communicate when she needs help.

An interview on 7/19/24 at 8:22 a.m., the Director of Staff Development (DSD) stated she expected staff to ensure call lights are in reach and added, if the call light is not in reach the resident cannot get the attention of nurses for care needs and may try to get up on their own and fall.

An interview on 7/19/24 at 11:44 a.m., the Director of Nursing (DON) stated she expected call lights be left in resident's reach and added, if call lights are not in reach residents may not be able to communicate with staff when they need help and could lead to resident becoming upset.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0919 A review of the facility's policy and procedure titled, Call System, Residents, dated September 2022, indicated, Residents are provided with a means to call staff for assistance through a communication system Level of Harm - Minimal harm or that directly calls a staff member or a centralized work station .Each resident is provided with a means to call potential for actual harm staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 47563

Residents Affected - Many Based on interview, observation, and record review, the facility failed to ensure the required in-service trainings for three of four sampled Contracted Certified Nursing Assistants (CCNA 1, CCNA 2, and CCNA3) and three of five sampled facility employed Certified Nursing Assistants (CNA 2, CNA 3, and CNA 4), when

the facility was unable to provide documentation to demonstrate the CCNAs and CNAs had no less than 12 hours per year of continuing competencies including dementia (a loss of memory and problem-solving abilities which interfere with daily life) management and abuse prevention.

These failures had the potential to result in CCNAs and CNAs not identifying and reporting abuse nor being able to effectively care for residents with dementia.

Findings:

In an interview on 7/18/24 at 2:59 p.m., the Director of Clinical Operations (DCO) stated the facility used contracted staff through staffing agencies and she expected those staffing agencies to provide CCNAs mandatory training documentation for facility to review before scheduling the CCNAs to perform patient care.

During a concurrent interview and observation on 7/18/24 at 3:04 p.m., the Staffing Coordinator (SC) stated

the facility used three staffing agencies for the CCNAs and the staffing agencies send over documentation to demonstrate the CCNAs completed the mandatory annual trainings. The SC logged onto two of the three staffing agency's online portals to look for documentation to demonstrate the CCNAs had completed the abuse prevention and dementia management trainings. The SC confirmed she could not find any documentation to support the CCNAs had completed any of the mandatory annual trainings.

During a concurrent interview and observation on 7/19/24 at 8:22 a.m., the Director of Staff Development (DSD) stated she did not have a specific training plan for the CCNAs, she would encourage them to attend any in-service trainings hosted by the facility if they were present when trainings occurred, and she believed

the staffing agencies provided the CCNAs with annual mandatory trainings including abuse prevention and dementia management.

During a concurrent record review and interview on 7/19/24 at 1:53 p.m. with the Regional Operations Director (ROD) and the DCO. All three staffing agency contracts were reviewed. The ROD confirmed two of

the contracts indicated the facility was responsible to provide contracted staff with trainings and the third contract did not indicate who was responsible for trainings. The DCO confirmed the facility was responsible to ensure the CCNAs completed annual trainings prior to working in the facility. The ROD stated he would follow up with the staffing agencies to request training documents for contracted staff who have worked in

the facility.

A review of CCNA employee records conducted on 7/19/24 indicated the following:

-CCNA 1 worked in the facility on 7/10/24 and 7/13/24. There was no documented evidence to support CCNA 1 completed dementia management training or completed at least 12 hours of training within the last year or prior to working in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 38 555645 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555645 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Auburn Ravine Healthcare Center 750 Auburn Ravine Road Auburn, CA 95603

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 0947 -CCNA 2 worked in the facility 21 times since 6/6/24. There was no documented evidence to support CCNA 2 completed dementia management training or completed at least 12 hours of training within the last year or Level of Harm - Minimal harm or prior to working in the facility. potential for actual harm -CCNA 3 worked in the facility on 7/14/24. There was no documented evidence to support CCNA 3 Residents Affected - Many completed dementia management training or completed at least 12 hours of training within the last year or prior to working in the facility.

In an interview on 7/19/24 at 3:29 p.m., the ROD stated he reviewed the available CCNA training records and confirmed the facility could not show complete mandatory annual training records for CCNAs.

A review of CNA employee records conducted on 7/19/24 indicated no documented evidence to support CNA 2, CNA 3, and CNA 4 completed training for dementia management and abuse prevention, or completed at least 12 hours of training within the last year.

In an interview on 7/19/24 at 3:53 p.m., the ROD stated he reviewed the CNA training documents for CNA 2, CNA 3, and CNA 4 and confirmed the facility did not have documentation to support the CNAs completed mandatory annual trainings as required.

In an interview on 7/19/24 at 4:14 p.m., the DCO stated she reviewed the CNA training documents for CNA 2, CNA 3, and CNA 4 and confirmed the facility did not have the documentation to support the CNAs completed mandatory annual trainings as required.

A review of the facility policy and procedure Competency of Nursing Staff, revised May 2019, indicated, . nursing assistants employed (or contracted) by the facility will: participate in facility-specific, competency-based staff development and training program and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents .The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population .The type and amount of this training is based on the facility assessment .

A review of the Facility Assessment Tool, dated 6/25/24, indicated, .Our resident profile .common diagnosis . Alzheimer's disease (a progressive disease that destroys memory and other important mental functions which interfere with activities of daily living), non-Alzheimer's dementia .staff training/education and competencies .Required in-service training for nurse aides. In-service must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 38 555645