Chico Terrace Care Center

F-F803)

A standardized recipe is a recipe that has been developed and tested using specific quantities of specific ingredients, with specific instructions, cook times and temperatures to ensure that a consistent product (appearance, flavor, texture, nutrient content) and number of servings (yield) is produced each time it is prepared.

Review of a facility policy titled Standardized Recipes, dated 7/1/14, showed food products prepared and served by the dietary department will utilize standardized recipes. Facility policy further indicated DM will monitor and routinely verify the recipes used by the cooks. Facility policy also noted recipe accuracy concerns will be reported to the Dietitian for evaluation and modification as necessary.

During an interview with [NAME] A on 3/03/25 at 11:40 AM, she stated their new menu was rolled out from corporate in June or July 2024. She stated many of the new recipes were inaccurate in their yields - either way too much or not enough for servings planned. She stated the Dietary Manager (DM) communicated with

the corporate dietitians about problem recipes, but it was a constant battle, and the cooks found a lot of errors in the recipes.

Review of a document titled Week at A Glance menu: Rockport Winter 2024, Week 1 showed dinner on Monday, Day 2 (3/3/25), the menu was to be Ham & Swiss on Croissant, Lettuce & Tomato, Condiments, Classic Macaroni Salad, Strawberries & Bananas with Whipped Topping, and Milk/Beverage.

During a concurrent observation and recipe review on 3/3/25 at 2:36 PM, [NAME] D did not prepare the Ham & Swiss on Croissant dinner sandwiches according to recipe. He used less ham and cheese than specified

in the recipe. He used white bread instead of croissants. He used American/Swiss pasteurized cheese instead of Swiss cheese. [NAME] D stated he was not sure why he did not follow the recipe. In a concurrent interview, the DM confirmed [NAME] D did not follow recipe. She stated they didn't use croissants because

they could only buy them frozen and unsliced, and they fell apart when staff sliced them. She stated the RD approved the substitution of white bread instead of croissant, so they use white bread every time this recipe was on the menu. When asked if their vendor had other croissant products available that would work in the recipe, the DM stated yes, but corporate controlled their order guide and they were not allowed to order the croissants that would work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 A review of the Nutrition Facts for [NAME] Round Top Bread, obtained through the facility's food vendor and provided by the RRD, showed two slices of the white bread used in the Ham & Swiss Croissant sandwich Level of Harm - Minimal harm or provided 200 calories. The Nutrition Facts for Croissant Butter Perfect Frozen showed one croissant potential for actual harm provided 280 calories. Cumulative substitutions over time could potentially impact the nutrients provided to residents over time, when compared to the facility's nutrient analysis of the menu. Residents Affected - Many

During an observation on 3/4/25 at 9:26 AM, [NAME] B prepared a baking sheet of Ranch-style chicken for lunch. A concurrent review of the recipe titled Ranch Style Chicken Breast, dated 2025, called for one gallon plus two cups of Ranch Style Dressing to be added to 18 3/4 pound of chicken breasts. [NAME] B did not follow the instructions in the recipe. She added cooking oil that was not called for in the recipe, and she was not observed putting ranch dressing onto the chicken breasts (Cross Reference

F-F804).

During an observation in the cook's area on 03/04/25 at 11:26 AM, [NAME] C was pureeing cookies. She assembled cookies, milk, and thickener. She didn't measure any of the ingredients. I think we need some more cookies. She added a little more thickener. She poured her pureed cookies with runny consistency into small dessert bowls. When asked if she used a recipe, she stated that if she went by what the recipe said,

the consistency didn't turn out like it was supposed to.

*2. Recipes did not consistently provide a palatable product

During a concurrent observation and interview on 3/4/25 at 1:02 PM, the RRD and two surveyors evaluated a pureed regular diet lunch test tray, and a regular lunch test tray for appearance, flavor, and texture. The RRD confirmed she did not taste ranch dressing flavor in the chicken breast. The RRD agreed the potatoes tasted like they had no seasoning. The RRD agreed the pureed cookie was stiff and gummy, and stated she thought the cookie didn't turn out properly because the cook rushed to make a new batch for the test tray.

A review of a recipe titled Roasted Red Potatoes showed it called for 10 pounds, 13 ounces of fresh red potatoes, one teaspoon of salt, (plus oil, paprika and pepper). A review of a recipe titled Mashed Potatoes with Gravy (PU4 = pureed) showed it called for Instant Mashed Potatoes, and brown gravy mix. No salt was included in the recipe.

During an interview with the RRD on 3/5/25 at 9:26 AM, she confirmed the recipe for potatoes called for one teaspoon of salt for ten pounds, 13 ounces of potatoes. RRD agreed this was not enough salt. RRD agreed chicken from test tray did not taste like it had ranch dressing.

During an interview on 3/5/25 at 9:52 AM, Resident 372 stated facility pork needed more seasoning.

During an interview on 3/5/25 at 10:01 AM, Resident 59 stated she wished the food tasted a little better.

During an interview with the DM, RDM, RRD (on the phone), and FRD (on the phone) on 3/6/25 at 1:20 pm,

the DM and RDM agreed the facility had no residents with a 2-gram sodium diet order that would prompt elimination of salt from cooking. The norm was to try to liberalize sodium restrictions to a no added salt salt diet, which allowed salt during cooking, but no extra salt packet on the resident's tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 50363 potential for actual harm Based on observation, interview, and record review the facility failed to ensure food was palatable and meat Residents Affected - Some easy to cut with a knife when four out of four residents interviewed (Resident 15, 18, 59, 372) stated the food needed more seasoning or salt and/or the meat was difficult to cut with the provided knife.

This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status.

Findings:

During an observation on 3/4/25 at 9:26 AM, [NAME] B prepared a baking sheet of Ranch-style chicken for lunch. A concurrent review of the recipe titled Ranch Style Chicken Breast, dated 2025, called for baking sheet to be greased, chicken breasts to be baked for 15 minutes, removed from oven, covered in ranch dressing, and put back in oven. Observed [NAME] B pour cooking oil into baking sheet, placed chicken breasts on baking sheet, removed from oven after 15 minutes, temperature checked with thermometer, and placed back into oven. [NAME] B was not observed putting ranch dressing onto the chicken breasts.

During an observation and concurrent interview on 3/4/25 at 1:02 PM, the Regional Registered Dietitian (RRD), and two surveyors transported two test trays, one a regular diet and texture, and the second a pureed regular diet, to the Director of Staff Development (DSD)'s office for evaluation. Both trays were evaluated by the RRD and two surveyors. All present agreed the temperature of the foods were acceptable.

During evaluation of the pureed tray, RRD stated if there was a dip in the mashed potatoes to hold some gravy, the plate would look nicer. RRD and surveyors agreed mashed potato tasted like it had no seasoning. RRD and surveyor agreed pureed cookie was sticky and gummy. On the regular tray, surveyor noted the chicken needed seasoning. RRD and surveyors agreed they could not taste ranch dressing flavor on chicken as recipe called for. RRD and surveyor agreed cubed potatoes had no flavor and needed seasoning.

During a concurrent interview on 3/5/25 at 9:26 AM, RRD confirmed that recipe for potatoes called for one teaspoon of salt for ten pounds of potatoes. RRD agreed this was not enough salt. RRD agreed chicken from test tray did not taste like it had ranch dressing.

During a concurrent interview on 3/5/25 at 9:26 AM, [NAME] B stated she used ranch dressing on the chicken breast. [NAME] B stated she did not drain the chicken after it baked for 15 minutes like recipe directed. [NAME] B confirmed she did not grease baking sheets according to recipe. [NAME] B confirmed

she poured an unknown amount of cooking oil onto baking sheets. [NAME] B stated she did not use ranch dressing on some of the chicken because there were residents who were lactose intolerant at facility. [NAME] B stated she did not know why the chicken without ranch dressing was on the regular test tray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0804 During a record review of 68 facility lunch meals tickets dated 3/4/25, indicated zero out of sixty-five residents as lactose intolerant. Further review showed one resident disliked Milk (beverage only), and Other Level of Harm - Minimal harm or dairy. Fourteen out of 68 lunch meal tickets showed a dislike Milk (beverage only). During a subsequent potential for actual harm interview with the DM on 3/6/25 at 1:20 pm, DM stated they had one resident with no lactose on their tray ticket. She confirmed that dislikes Milk (beverage only), meant the resident didn't drink milk, but consumed it Residents Affected - Some as an ingredient and liked another dairy.

During an interview on 3/5/25 at 9:52 AM, Resident 372 stated facility chicken was way overdone. Resident 372 stated pork is also difficult to cut and needed more seasoning.

During an interview on 3/5/25 at 9:54 AM, Resident 15 stated flavor of facility food is okay. Resident 15 stated facility served too much chicken, which was sometimes difficult to cut.

During an interview on 3/5/25 at 10:01 AM, Resident 59 stated she did not like facility food. Resident 59 stated the meat served to residents was difficult to cut. Resident 59 wished food tasted a little better.

During an interview on 3/5/25 at 10:15 AM, Resident 18 stated facility chicken is hard to chew and cut. Resident 18 stated she wished meat was easier to cut.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 50363 Residents Affected - Many Based on observations, interviews, and record review, the facility failed to ensure all residents were consistently offered evening bedtime snacks per facility policy for four out of four sampled residents (Resident 372, 15, 59, 34). Facility also failed to ensure snacks were stocked at two out of two nursing stations per facility policy.

This failure had the potential to negatively affect nutrition status and wellbeing of all residents. The facility census was 72.

Findings:

During a record review of facility policy titled Nourishment and Snacks 4/1/14, indicated Individual and/or bulk snacks are available at the nurse's station for consumption by residents. Additional snacks may be made available upon resident request. Facility policy further indicated rotation of snacks is indicated on the menu spreadsheet for hour of sleep (HS - nighttime) snacks .bulk HS snacks are provided to each nursing station daily.

During an interview on 3/5/25 at 10:55 AM, Resident 372 stated he was not offered snacks by staff, but would like to be offered snacks and would take them if offered.

During an interview on 3/5/25 at 10:55 AM, Resident 15 stated he was not offered snacks by staff, but would like to be offered snacks and would take them if offered.

During an interview on 3/5/25 at 10:55 AM, Resident 59 stated she was not offered snacks by staff, but would like to be offered snacks and might want some if they were offered.

During an interview on 3/5/25 at 10:55 AM, Resident 34 stated he had to ask for snacks from staff if he wanted them. Resident 34 stated staff did not offer him snacks.

During an interview on 3/5/25 at 3:03 PM, Dietary Manager (DM) stated residents could receive snacks at 10:00 AM, 3:00 PM, and 7:30 PM. DM stated she entered snack preferences into her kitchen documentation and printed out labels to add to resident snacks. DM stated if a resident wanted a snack and kitchen was closed, staff could obtain a snack from either nursing station. DM stated snacks included sandwiches, cheese sticks, crackers, and fresh fruit. DM stated nursing staff informed her if nursing stations ran low on snack stock.

During an interview on 3/5/25 at 3:45 PM, Licensed Vocational Nurse (LN) I at nursing station 2 stated residents could request snacks at night from staff. LN I stated if residents were not on the snack list, the charge nurse had a key to the kitchen and could retrieve snacks. LN I stated if nursing station 2 ran out of snacks, staff could get them at nursing station 1 or the charge nurse could restock the nursing station snacks from kitchen the kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0809 During an observation on 3/5/25 at 3:40 PM, nursing station 2 did not have resident snacks (sandwiches, cheese sticks, crackers, and fresh fruit) stocked in the refrigerator or freezer. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/5/25 at 3:42 PM, nursing station 1 did not have resident snacks (sandwiches, cheese sticks, crackers, and fresh fruit) stocked in the refrigerator or freezer. Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 50363

Residents Affected - Many Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when:

1) Fixed equipment (Fixed equipment is equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) was not clean.

2) Apron was not changed between cleaning dishes and preparing food. Apron was not worn when soiled counter was cleaned.

3) Dietary staff touched face with gloved hands when trays were loaded onto cart and did not change gloves or wash hands. Dietary staff touched tops and bottoms of dessert bowls and scooped Jell-O into them without gloves.

4) Cabinets, floors and walls were uncleanable.

5) Evidence of roaches under one sink.

6) Chlorine concentration was outside of acceptable parameters.

7) Ice machine was not cleaned according to manufacturer recommendations.

These practices had the potential to result in foodborne illness for residents from food prepared by the facility food services staff.

Findings:

1) During an observation in the kitchen on 3/3/25 at 8:04 AM, rusted shelving was identified in fridge/freezer room where dried food was stored. A white, dried substance was identified on the same shelving unit. The industrial mixer had areas of dried food on the bottom of the stand and behind the bowl. The Extreme Blender had dried food on motor base, buttons and there was a wet, brown ring under the blades inside the blender. The steamer had dried food on the buttons and inside of the handle. The KitchenAid timer and thermometer used to temperature check resident food had dried food and dust on them. Three out of three large pots were burnt on the bottom and warped. The inside of all three large pots were pitted throughout. Three out of four nonstick frying pans had scratches and pitting throughout the cooking surface. One extra large pot was pitted on throughout the inside, had a burnt bottom, and a large, warped bubble on the base. There was tape residue on the stainless counter where staff taped recipes in food preparation area. Dust was noted on large green dish storage rack. The canned food storage racks in the Dietary Manager (DM)'s office were rusted. Four out of eight knives in wall storage had food residue on them. Dried liquid was noted

on top of white arctic air freezer where lit pots are stored to dry in fridge/freezer room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 observation on 3/3/25 at 10:58 AM, observed window by dishwashing sink with accumulated dust and dirt. Observed the window fan had dust collected on blades. Two out of three window fans were Level of Harm - Minimal harm or observed with accumulated dust. potential for actual harm

During an observation and concurrent interview on 3/4/25 at 8:57 AM, [NAME] B used a wood handled Residents Affected - Many plastic bristle brush to butter rolls. [NAME] B stated brush was cleaned by dishwasher and sanitizer machine. Observed brush bristles were worn and broken.

During an observation and concurrent interview on 3/4/25 at 9:01 AM, Regional Registered Dietician (RRD) confirmed top of gaskets in fridge/freezer room on white arctic fridge were dirty. RRD also confirmed top of fridge was dirty. RRD confirmed tape residue on stainless counter and containers on shelves in fridge/freezer room was a potential source of cross contamination.

During a concurrent interview on 3/4/25 at 9:09 AM, DM and RRD confirmed there was dried food and food build up on the base of the industrial can opener and a potential source of cross contamination. DM and RRD confirmed KitchenAid timer and thermometers used to temperature check resident food on top of steamer were not clean. DM and RRD confirmed grease build up on hand and buttons of steamer. DM and RRD confirmed industrial mixer was not cleaned per manufacturer instructions. DM and RRD confirmed Extreme blender base was not cleaned and had food build up. RRD stated she saw dried food in blender buttons, cracks and crevices.

During a record review of facility policy titled Can Opener use and Cleaning 10/1/2014, indicated the can opener will be sanitized between uses. Facility policy further indicated shank of can opener was to be removed and scrubbed, rinsed with clean water, sanitized with sanitizing solution, and air dried. Facility policy also indicated the base plate attached to the counter was to be scrubbed with hot detergent solution and brush, sanitized, and air dried.

During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated the walls, ceiling, and floor should be maintained in good repair and regularly cleaned. Facility policy further indicated shelving should be .smooth and easily cleaned.

2) During an observation on 3/4/25 at 10:10 AM, observed Dietary Aide (DA) B with no apron, stretched over soiled counter to clean the counter and back splash. DA B sprayed water to rinse counter and back splash and was sprayed with overspray.

During an observation on 3/4/25 at 11:46 AM, [NAME] B was observed with a black apron when she cleaned

the Robocoupe (a food processor appliance) bowl, lids and blades. [NAME] B wore the same black apron when she returned to food production.

During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated staff were to wear clean aprons and change as often as needed.

3) During an observation on 3/4/25 at 11:08 AM, [NAME] C was observed loading lunch meal trays with gloves on. [NAME] C scratched her face with gloved hands and continued to place items on trays without washed hands or changed gloves. [NAME] B was observed with elbow/forearm draped across Robocoupe base during food preparation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 observation and concurrent interview on 3/6/25 at 11:25 AM, DA A was observed with no gloves when she prepared dessert. DA A touched the tops and bottoms of the dessert bowls when she placed them Level of Harm - Minimal harm or on the tray. DA A was observed scratching her nose with one ungloved hand. DA A did not wash her hands. potential for actual harm DA A continued to scoop red Jell-O into the dessert cups ungloved. DA A stated she was not sure if she should wear gloves when she prepared the dessert cups. Residents Affected - Many

During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated proper hand washing should occur after touching bare human body parts other than clean hands and arm, and during food preparation, as often as necessary to prevent cross contamination when changing tasks.

4) During a concurrent observation and interview on 3/3/25 at 8:04 AM, observed worn finish on front of cabinet drawers and doors next to industrial mixer, front of cabinet doors at coffee station in corner, corners of walls in fridge/freezer room with chipped paint area. Observed floor in fridge/freezer room was damaged in three areas. DM confirmed these areas were damaged and uncleanable. DM stated there were no current plans to replace or repair these areas. DM stated Administrator (Admin) was aware of the issues.

During an interview on 3/4/25 at 9:01 AM, RRD confirmed floors in fridge/freezer room were damaged and not a cleanable surface. RRD confirmed worn finish on front of cabinets and drawers in kitchen were not cleanable surfaces.

During a record review of facility policy titled Floor Safety 11/1/2014, indicated that floors shall be maintained

in a safe manner.

5) During an observation and concurrent interview on 3/3/25 at 8:04 AM, two roach pheromone pesticide boxes were observed under the sink at the coffee station. One box in the back right corner was dated 1/16/24. The second box was not dated. A dried brown, kidney-shaped object approximately 3/4 of a centimeter in length was observed next to the second box. Observed coffee ground substance scattered under the sink in both back corners and throughout the surface of the inside of the cabinet. DM stated there was not any pest issues. DM confirmed there were two roach traps under the sink and stated the pesticide boxes were a preventative measure.

During an interview on 3/4/25 at 9:01 AM, RRD confirmed two roach traps under the sink in the kitchen.

During an interview on 3/5/25 at 3:57 PM, Registered Dietician (RD) stated during the two monthly kitchen inspections she completed since the start of her employment in December 2024, she noted no pest issues in

the kitchen.

During an interview on 3/6/25 at 9:20 AM, Maintenance Technician (MT) stated he put the roach traps under

the sink in the kitchen. MT stated he forgot about them. MT stated facility pest vendor treated outside of facility only. MT stated he looked at roach traps two months ago. MT stated he did not notify DM, RD or dietary staff of evidence of pests or roach traps. MT stated he should have consulted with facility pest vendor regarding evidence of roaches in kitchen.

During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated area should be monitored routinely for pest activity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 6) During a concurrent observation and interview with DA C on 3/3/25 at 2:55 PM, DA C stated chlorine level

in sanitizer machine need to be between 50-100 parts per million (ppm) on a test strip. DA C tested chlorine Level of Harm - Minimal harm or concentration, and it was observed that chlorine concentration was 200 ppm. DA C stated chlorine was too potential for actual harm concentrated. DA C stated he did not know if that was a problem. DM stated, using too much chlorine is not

a problem. DM stated if chlorine levels were too high, she would call the company to fix the machine. Residents Affected - Many 7) During an observation on 3/3/25 at 3:25 PM, MT demonstrated his procedure to clean facility ice machine. MT stated facility policy was for ice machine to be cleaned monthly. MT stated he did not clean ice machine February 2025 because February was a short month. Observed Hoshizaki ice machine located in Harmony dining hall. MT stated ice machine was six months old. MT stated ice machine was last cleaned 1/30/25. MT confirmed he did not do the sanitizer process. MT stated he only does sanitization process with bleach every few months. MT stated he was not aware that both cleaning and sanitizing processes were required each time he cleaned the ice machine. Observed mineral deposit build up inside of ice machine. MT stated mineral deposit build up was difficult to avoid with area water supply. MT stated he last changed ice machine filter 12/30/24. MT stated he would try to change ice machine filter monthly in an attempt to avoid mineral deposit build up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 42448 potential for actual harm Based on observation, interview and record review the facility failed to ensure conditions essential to the Residents Affected - Many sanitation of the kitchen were maintained when uncleanable surfaces were not repaired or replaced.

This failure had the potential to result in cross contamination, the attraction of pests, and foodborne illness for all residents consuming food from the facility.

Findings:

A review of the Food and Drug Administration (FDA) 2022 Food Code, Section 4-202.16, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

A review of facility policy titled Maintenance Service, dated 1/1/12, showed The Maintenance Department maintains all areas of the building, grounds, and equipment .in compliance with current federal, state and local laws, regulations, and guidelines.

During an observation in the kitchen on 3/03/25 at 8:04 AM, the floor in the refrigerator/freezer room was damaged and uncleanable in three locations. In addition, the walls, doorways, and doors in multiple kitchen locations had worn paint, chipped paint, creating uncleanable surfaces.

During an observation in the cook's food preparation area on 3/03/25 at 8:35 AM, the wood cabinets were worn and uncleanable. The area under the corner sink did not have cleanable surfaces, was not clean, and contained two cockroach traps and evidence of cockroaches (Cross Reference

F-F812).

Glove Use:

During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated proper hand washing should occur after touching bare human body parts other than clean hands and arm, and during food preparation, as often as necessary to prevent cross contamination when changing tasks.

During an observation on 3/4/25 at 11:08 AM, [NAME] C was observed loading lunch meal trays with gloves on. [NAME] C scratched her face with gloved hands and continued to place items on trays without washed hands or changed gloves. [NAME] B was observed with elbow/forearm draped across Robocoupe (a food processer appliance) base during food preparation.

During an observation and concurrent interview on 3/6/25 at 11:25 AM, DA A was observed with no gloves when she prepared dessert. DA A touched the tops and bottoms of the dessert bowls when she placed them

on the tray. DA A was observed scratching her nose with one ungloved hand. DA A did not wash her hands. DA A continued to scoop red gelatin into the dessert cups ungloved. DA A stated she was not sure if she should wear gloves when she prepared the dessert cups.

Apron Use:

During a record review of facility policy titled Dietary Department - Infection Control 6/4/2024, indicated staff were to wear clean aprons and change as often as needed.

During an observation on 3/4/25 at 10:10 AM, observed Dietary Aide (DA) B with no apron, stretched over soiled counter to clean the counter and back splash. DA B sprayed water to rinse counter and back splash and admitted she was sprayed with overspray. She returned to meal tray assembly processes with her potentially contaminated clothing and no apron.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0802 During an observation on 3/4/25 at 11:46 AM, [NAME] B was observed with a black apron when she cleaned

the Robocoupe bowl, lids and blades. [NAME] B wore the same black apron when she returned to food Level of Harm - Minimal harm or production. potential for actual harm *3. Staff did not follow standardized recipes (Cross Reference

F-F925). [NAME] drawers in the cook's area held serving utensils and clean towels, had grime and gouges, were not clean or cleanable, and the cooks had difficulty opening and closing the drawers. The Formica surface in the corner food prep area was worn thin, and was broken near the trash can, creating uncleanable surfaces. In a concurrent interview, [NAME] A stated the wood drawers were often difficult to open and close.

During an observation on 3/03/25 at 11:40 AM, [NAME] A had difficulty opening the cook's wood utensil drawer, and also the metal drawer near the two-compartment.

During an observation and concurrent interview with the Regional Registered Dietitian (RRD) on 03/04/25 at 9:00 AM she confirmed the floor in the refrigerator/freezer room was damaged and stated, Not a cleanable surface.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0908 During an interview with the Maintenance Technician (MT) on 3/06/25 at 9:20 AM, he stated he did regular monthly inspections of the kitchen. He cleaned filters, coils, looked in corners and behind large equipment to Level of Harm - Minimal harm or ensure sanitation, checked grease traps, checked the vendor's weekly dish machine service was being potential for actual harm done. He stated that as far as he knew, there was nothing in the works yet to replace the wood cabinets in

the kitchen. When asked about the floor gouges, and the worn and chipped paint in the kitchen, MI stated I'm Residents Affected - Many one person. I'm doing the best that I can. He stated he had no other maintenance staff to help, and he tried hard to juggle the budget to have what he needed to maintain the facility.

50363

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 50363 potential for actual harm Based on observation, interview and record review the facility failed to maintain an effective pest control Residents Affected - Many program when:

*1. The facility did not have an effective system in place to track and monitor pest control issues in the facility.

*2. Cockroach traps, and evidence of cockroach presence were found in a cabinet under a food preparation sink in the facility kitchen.

These failures had the potential to result in transmission of disease, or to trigger allergies or asthma for 72 residents living at the facility.

Findings:

The Food and Drug Administration (FDA) Food Code 2022, 6-501.111 showed: The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or, other means of pest control (D) Eliminating harborage conditions (conditions that encourage pests to live and grow).

During a record review of facility policy titled Pest Control 1/1/12, indicated the facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. Facility policy further indicated a pest control company will inspect the facility and grounds for pests that may cause damage to the facility .submit a written report to the Administrator (Admin) detailing its findings .submit

a site-specific work plan for each area/department with recommendations on how to keep the facility pest-free .department staff are responsible for carrying out these recommendations to prevent pests in their respective areas. Facility policy also indicated any pesticides used must be placed in locations inaccessible to staff and away from food storage areas, and facility staff will report to the housekeeping supervisor any sign of rodents or insects.

During a record review of facility policy titled Food Storage and Handling 6/4/2024, indicated area should be monitored routinely for pest activity.

During an observation on 3/3/25 at 8:35 AM, two roach pheromone pesticide boxes were observed under the corner sink in the cook's food preparation area. One box in the back right corner was dated 1/16/24. The second, newer-looking box was not dated. A dried brown, kidney-shaped object approximately 3/4 of a centimeter in length was observed next to the second roach pheromone pesticide box. A black splatter-looking substance resembling cockroach droppings were scattered throughout the bottom, back, sides and corner surfaces inside of the cabinet under the sink. If any of the splatter existed back to placement of pheromone boxes, it had not been cleaned, and the surfaces under the sink were not maintained in a cleanable condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0925 In a follow-up interview with the Dietary Manager (DM) on 3/3/25 at 9:01 AM, she stated the kitchen had no problems with pests. During a concurrent observation of the interior cabinet under the cook's prep sink with Level of Harm - Minimal harm or the DM and Regional Registered Dietician (RRD), the DM and RRD confirmed the cabinet contained two potential for actual harm cockroach pheromone boxes, and the DM stated they were a preventative measure.

Residents Affected - Many During an interview with the Maintenance Technician (MT) on 03/04/25 at 10:45 AM, he was asked about the facility's pest control program, and documentation of the pest control services over the past year were requested. The MT responded he had no records that provided much information about the facility's pest problems, the locations where past problems occurred, or what was done by the pest control company to eradicate the pests. He explained that when pest problems were identified, he sent text messages to their pest vendor, and the vendor came out and took care of it. He stated the facility received invoices for the service calls, but the invoices did not include any information about what pests were found, the location of pests, what was actually done to eradicate the pests, or monitoring to ensure the pest control was effective. MT stated the only records of pest details were in texts on his mobile phone. MT stated he was unaware of any pest issues in the kitchen. In a concurrent observation, MT was shown the evidence of cockroaches under the sink in the cook's prep area in the kitchen. MT stated he called the Pest control vendor who stated

he would get help to pull the facility's service details up in his computer and would provide them to the facility.

During an interview on 3/5/25 at 3:57 PM, the Facility Registered Dietitian (FRD) stated during the two monthly kitchen inspections she completed since the start of her employment in December 2024, she noted no pest issues in the kitchen.

During an interview with the Accounts Payable staff (AP) on 03/06/25 at 07:55 AM, she confirmed she never received anything from the pest control vendor other than the invoice. She had never received any reports about the pest control services provided.

A review of documents provided from the pest control vender to MT were titled Service Inspection Report from the facility pest control vendor showed the facility had been combating cockroaches since 8/16/24. The facility continued to have pests:

8/16/24 Treated outside perimeter for roaches

9/4/24 Treated outside perimeter for roaches

10/2/24 Treated outside perimeter for roaches

11/19/24 Treated outside perimeter for roaches

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 055516 Department of Health & Human Services Printed: 09/04/2025 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 055516 B. Wing 03/06/2025

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

Chico Terrace Care Center 188 Cohasset Lane Chico, CA 95926

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 0925 During an interview with MT on 03/06/25 at 9:20 AM, he stated he put the cockroach pheromone traps under

the sink in the kitchen. He just forgot about it. He stated the pest vendor treated the outside of the building Level of Harm - Minimal harm or only, but the facility put traps in interior locations and tried to remove food sources. When asked about potential for actual harm monitoring of the cockroach traps in the kitchen, MT stated they were being monitored. He stated he looked at them about 2 months previously when a drain in the kitchen was clogged with grease. When asked if Residents Affected - Many anything else should be done when pest problems were discovered, he stated he consulted with the pest control vendor and went from there. When asked why the area under the sink wasn't cleaned to remove existing contamination, and why it was not painted to create a cleanable surface he did not have an answer.

He stated he did not notify the food service manager, the FRD or anyone else about the pest evidence in the kitchen or the traps put in place. MT stated he should have consulted with facility pest vendor regarding evidence of roaches in kitchen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 055516