Lincoln Meadows Care Center

F-F812, #6).

These failures had the potential to place 88 out of 92 highly susceptible residents who consumed food from

the facility at risk for food borne illness.

Findings:

1. During an interview with DA 1 regarding the process of manual dishwashing by the 2-compartment sink on 3/11/25 at 8:57 a.m., DA 1 stated he would switch to manual dishwashing when the dishwashing machine was not working. He stated the steps were washing, rinsing and air-dried.

A concurrent confirmation with Dietary Manager (DM) and stated the correct process were washing, rinsing, sanitizing and air-dried. For the sanitizing step, DA 1 stated the dishes would immerse into the sanitizer solution for 5 to 10 minutes. DA 1 could not state the effective concentration for the sanitizer solution when asked. DM cued DA 1 to read the instruction posted on the wall, and DM stated the concentration should be at the range of 200-400 ppm (parts per million - a measurement unit for the sanitizer solution).

A review of facility policy and procedure (P&P) titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the process involved washing, rinsing, sanitizing, and air-dried, and .sanitizer solution . must read 200-400 ppm .immerse all washed items (in the sanitizer solution) for at least 1 minute (60 seconds) .

2. During a kitchen observation on 3/11/25 at 8:34 a.m., it was noted the storage areas for clean metal pans was not clean with food debris. Observed DA 2 used a towel to wipe the storage areas. DA 2 stated she used the towel from the red bucket (bucket contained sanitizer solution) to clean the storage areas.

During an interview with DM on 3/11/25 at 8:45 a.m., DM confirmed and stated DA 2 used the sanitizer to clean the soiled storage areas. DM stated DA 2 did not performed the procedure correctly. He further stated DA 2 should first clean with soap and water, then using the sanitizer to sanitize.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 A review of department document titled, Inservice: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, dated 3/2022, indicated, .cleaning and sanitizing of .food contact surfaces .food storage areas are vital in Level of Harm - Minimal harm or keeping food wholesome and safe to consume .Cleaning is the removal of soils, tarnishes, or stains . potential for actual harm Sanitizing is the process of reducing the number of microorganisms on the surface to safe levels so that they cannot cause disease or food spoilage .to be effective, cleaning and sanitizing must be a two-step process. Residents Affected - Some Surface must first be (1) cleaned and rinsed before (2) being sanitized .any surface that comes in contact with food much also be cleaned and sanitized .

3. A concurrent observation and interview with DA 2 and DM regarding the preparation and testing of the sanitizer solution for the red bucket was conducted on 3/11/25 at 8:34 a.m. DA 2 stated the sanitizer solution was pre-mixed and she got the solution from the dispenser. She stated she would test the effective concentration of the solution by using the test strip and the concentration range should be 200-400 ppm. DA 2 demonstrated how to test the effectiveness of the sanitizer solution. She used the test strip by dipping the sanitizer solution for more than 15 seconds and took it out to compare the color chart (different colors from

the chart corresponds to different concentration (ppm) range includes: 0, 150, 200, 400 and 500) on the test strip container. Then she used the same test strip to dip into the solution again.

DM confirmed and stated DA 2 should not dip in the solution again and test strip should dip in the solution for 10 seconds. DA 2 stated when she prepared the solution, she usually dipped the test strip in the solution more than 10 seconds because the color would not change. She further stated the solution should be cold.

The solution was cold when touch and took the temperature with thermometer with the result was 59.7 degrees Fahrenheit (F).

DM verified and stated the solution was fine because it was cold. A concurrent review of the instruction of

the test strip container, it stated, .dip paper (test strip) in quat (sanitizer) solution, not from surface, for 10 seconds .testing solution should be between 65-75 degrees F . DM stated he was not aware of the temperature range and would contact the sanitizer vendor to adjust the temperature.

A review of facility P&P titled, Quaternary Ammonium Log Policy, dated 2023, indicated, .Read instructions

on quaternary container and the test strip for proper concentration length of time the strip needs to be in contact with the solution, and if temperature of the solution is to be considered when testing for concentration .Follow container and test strip instructions. A high concentration may potentially hazardous and may be a chemical contaminate of food.

A review of DA 1's employee file, it indicated his date of hire was on 2/28/23 for dietary aide position. Review

the job description for dietary aide, it stated the position required food handler's certificate. DA 1's file did not have any certificate. An interview with DM on 3/13/25 at 10:38 a.m., DM confirmed and stated DA 1 did not have any food handler's certificate.

A review of DA 2's employee file, it indicated her date of hire was on 2/14/23 for a position as a cook. A

review of the job description for a cook, it stated the position required ServSafe (set of training courses for food safety) food handler certificate. DA 2's file did not have any certificate. An interview with DM on 3/13/25 at 10:38 a.m., DM stated D2 should be hired as dietary aide position and not sure why her position changed to be a cook. DM confirmed and stated DA 2 did not have any food handler's certificate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 A review of facility documents titled, Verification of Job Competency Demonstration - Diet Aides, for DA 1 and DA 2, both completed for the year of 2024 by DM, indicated DA 1 was competent on Emergency dish Level of Harm - Minimal harm or washing procedure and when to use it, and DA 2 was competent on How to clean and sanitize equipment, potential for actual harm counter top and Sanitizing solution; preparation, test concentration and record results; when to replace solution by demonstration and verbalization. Residents Affected - Some

A review of departmental document titled, Food & Nutrition Service In-Service, Topic: Competency Checks Update and Inspection List, completed on 10/28/24 and added on dates of 11/21/24, 12,20/24 and 1/22/25 and given by DM. The document showed DA 1 and DA 2 attended the in-services. There was no individual lesson plans referred to the different competency topics. A concurrent interview with DM on 3/13/25 at 9:22 a. m., DM stated the topic Competency Checks Update and Inspection List was to review everything for the competency subjects to prepare the staff for survey.

A review of facility job description titled, Director of Food and Nutrition (DM), dated 2/2018, it stated, . Essential Job Functions .provide .training .oversee that proper levels of cleanliness and sanitation within the department .plan and conduct staff meetings and in-service education programs on dietary policies and procedures .Practice and ensure compliance of infection control policies and procedures of the department and facility .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 40830

Residents Affected - Many Based on observation, interviews, and record review, the facility failed to ensure the planned menu was followed for the therapeutic diets (modified diets from 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 lunch on 3/12/25 when:

1. 19 Residents (Resident (3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291, and 341) with regular portion with regular texture diets got 6 ounces (oz.) (3/4 cup) of pasta instead of 4 oz. (1/2 cup)

2. 11 residents (Resident 19, 23, 24, 30, 32, 36, 44, 57, 60, 72, and 85) with CCHO (Consistent Carbohydrate) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) and CCHO Renal (kidney) diet (a diet to manage chronic kidney disease and diabetic disease) got one serving of dessert (lemon snow bar) and 6 oz. of pasta instead of half (1/2) serving of dessert and 4 oz. of pasta

3. Four residents (Resident 9, 34, 76, and 340) with small portion with diets received one serving of dessert, 6 oz. of pasta and 6 oz. chicken instead of 1/2 serving of dessert, 4 oz. of chicken and 2 oz. (1/4 cup) of pasta

4. Two residents (Resident 17 and 58) with fortified (add extra calories and nutrients) diet (diet designs for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status) did not receive 1/2 oz. of melted margarine on the vegetables

5. Three residents (Resident 14, 65 and 73) with finger food diet did not receive the dessert cut in half

6. 88 out of 88 residents who received meals form the facility kitchen did not receive garnish (food decor to enhance the presentation of meals to help increase appetite) with their lunch meals.

These deficient practices had the potential to result in residents having meals which did not meet their nutritional needs and compromising the medical and nutrition status of the 88 residents who consumed meals from the facility kitchen.

Findings:

During the lunch meal distribution on 3/12/25 beginning at 11:52 a.m., it was noted as followed:

Observed there were one kind of serving utensils (6 oz.) for serving chicken and pasta, and a concurrent

interview with [NAME] (CK) to confirm both serving sizes were 6 oz. For the dessert (lemon snow bar, one serving measurement: 2 inches long x 2 inches wide x 1/2 inch height), CK stated she prepared only one serving size for all the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 1. 19 residents (Resident 3, 4, 5, 7, 22, 29, 33, 35, 47, 52, 56, 63, 66, 68, 75, 79, 82, 291 and 341) with regular portion with regular texture received 6 oz. of pasta. Level of Harm - Minimal harm or potential for actual harm A concurrent review of facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Spring Cycle Menus, Week 2 Wednesday, indicated regular portion Residents Affected - Many with regular texture should receive 1/2 cup (4 oz.) of pasta.

2. 11 residents (Resident 19, 23, 24, 30, 32, 36, 44, 57, 60, 72 and 85) with CCHO and CCHO Renal diet received one serving of dessert and 6 oz. of pasta.

A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated CCHO and CCHO Renal diet should receive 1/2 serving of dessert and 4 oz. of pasta.

3. Four residents (Resident 9, 34, 76 and 340) with small portion with diets got one serving of dessert, 6 oz. of pasta and 6 oz. of chicken.

A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated small portion with diets should receive 1/2 serving of dessert, 2 oz. of pasta and 4 oz. of chicken.

4. Two residents (Resident 17 and 58) with fortified diets did not receive extra 1/2 oz. of melted margarine

on the vegetables as fortified food.

A concurrent review of facility document titled, Spring 2025 - Week 2, Fortified Breakfast, Fortified Lunch, Fortified Dinner, indicated fortified diet should give extra 1/2 oz. of melted margarine on the vegetables for lunch 3/12/25.

5. Three residents (Resident 14, 65 and 73) with Finger Food diet receive one whole piece of dessert.

A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated finger food diet should receive one serving of dessert cut in half.

6. 88 out of 88 residents who received lunch meals from facility kitchen did not get parsley garnish.

A concurrent review of facility spreadsheet titled, Spring Cycle Menus, Week 2 Wednesday, indicated all diets should have received parsley garnish.

An interview with Dietary Manager (DM) and a concurrent review of the spreadsheet on 3/12/25 at 1:19 p.m. was conducted. DM acknowledged and confirmed the issues found during the meal distribution. He stated his expectation for the staff should be accurate for the portion measurement of the food, and they should follow the menu or spreadsheet according to the therapeutic diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 Registered Dietitian (RD) on 3/13/25 at 12:27 p.m., RD acknowledged issues that were found during the meal distribution on 3/12/25. RD stated the staff should follow the menu and Level of Harm - Minimal harm or spreadsheet because it would provide the correct portions for the according therapeutics diets. She further potential for actual harm explained especially for CCHO diet, the portion sizes were to control blood sugar level. RD stated if the portion sizes are not being followed would lead to over- or under- nutrition. She explained the fortified foods Residents Affected - Many provided extra calories for the residents had weight loss or to stabilize weight. RD further stated the finger foods were given for the residents with mobility issues and helped them to maintain independence during eating.

A review of the facility's policy and procedure titled, Menu Planning dated 2023, it indicated, .menus are planned to meet nutritional needs of residents in accordance with established national guidelines .the facility's diet manual and diets are ordered by the physician should mirror the nutritional care provided by the facility .menus are written for regular and therapeutic diets in compliance with the diet manual .

A review of facility document titled, Job description, Cook, dated 10/2016, indicated the cook was to follow prepared menus and portion control guides .prepare special diets accurately .make the presentation of the food appealing to the residents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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** 40830

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

1. Various sizes of metal pans were found having issues stored in the clean and ready-to-use storage areas:

- Stacked wet

- Were not clean with food particles

2. The storage areas for storing the clean and ready-to-use metal pans were not clean

3. The blade of the can opener was not well maintained

4. Dietary Aide (DA) 1 was not able to verbalize the process of manual dishwashing by 2-compartment sink

5. DA 2 was not able to perform cleaning and sanitizing procedure correctly for the soiled food contact surface areas

6. DA 2 was not able to verbalize and demonstrate the correct procedure to prepare and test the sanitizer solution for the red bucket (red color-coded bucket is used as a standard of practice to contain sanitizer solution)

7. DA 3 did not have the hair restraint fully cover the hair

8. There were issues found for the resident's refrigerator:

- Residents' food did not label and date properly

- Outdated food did not discard in the freezer

- The interior of the refrigerator was not clean

These failures had potential to cause food-borne illness in a highly susceptible population of 88 out of 88 residents who received food from the facility kitchen.

Findings:

1. During a concurrent observation and interview on [DATE REDACTED] at 8:23 a.m. with Dietary Manager (DM), DM confirmed the following items were stack wet and had food particles stored in the clean and ready-to-use storage areas:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 - five of full sheet metal pans (stacked wet; 4 out of 5 had red and white

Level of Harm - Minimal harm or particles) potential for actual harm - one of ,d+[DATE REDACTED] sheet metal pan (had red particles) Residents Affected - Many - 10 of ,d+[DATE REDACTED] sheet metal pans (stacked wet)

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

DM stated the dishes, pans and pots should be completely dried and clean before stored away. He further stated the staff who put away the dishes should check if they were clean and dried before stored away.

During an interview with Registered Dietitian (RD) on [DATE REDACTED] at 12:27 p.m., RD stated the dishes, pans and pots should be clean and air-dried before stored away.

A review of facility policy and procedure (P&P) titled, Dishwashing, dated 2023, indicated, .Dishes are to be air dried in racks before stacking and storing .

A review of facility P&P titled, Sanitation, dated 2023, indicated, .all utensils .shall be kept clean, maintained

in good repair .

2. During an inspection of the condition of the metal sheet pans stored at the storage areas at [DATE REDACTED] at 8:46 a.m., it was noted the storage areas (the areas used for storing clean and ready-to-use metal sheet pans) were not clean with particles on them.

A concurrent interview with DM, DM confirmed and stated the particles were food debris. He further stated

the storage areas should be clean, and the staff usually clean them daily.

During an interview with RD on [DATE REDACTED] at 12:27 p.m., RD stated the storage areas for storing dishes, pans and pots should be clean.

A review of facility P&P titled, Sanitation, dated 2023, indicated, .all .counters, shelves .shall be kept clean, maintained in good repair .

3. During a kitchen inspection and a concurrent interview of DM on [DATE REDACTED] at 10:45 a.m., it was noted the blade of can opener with discoloration and the blade surface was chipped. DM confirmed and stated the blade was chipping away and needed replacement. He further stated it was one of the findings during the facility internal inspection.

A review of facility P&P titled, Can Opener and Base, dated 2023, indicated, Proper sanitation and maintenance of the can opener .is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade or worn out cogwheel .Replace blade on can opener, as needed .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 4. During an interview on [DATE REDACTED] at 8:57 a.m. with Dietary Aide (DA) 1, DA 1 stated if the dishwashing machine was not functioning, he would switch to manual dishwashing with 2-compartment sink. DA 1 stated Level of Harm - Minimal harm or the steps were washing, rinsing and air-dried. He stated No when asked if he was missing a step. potential for actual harm

A concurrent interview with DM, DM verified and stated the correct process were washing, rinsing, sanitizing Residents Affected - Many and air-dried. DM stated they had a big tub worked as third compartment filled with sanitizer solution for sanitizing step. Asked DA 1 how long the dishes should immerse in the sanitizer after the rinsing step, and

he stated 5 to 10 minutes. DA 1 stated he did not know the effective concentration for the sanitizer was when asked. DM cued DA 1 to read the instruction posted on the wall and DM stated the concentration should be at the range of ,d+[DATE REDACTED] ppm (parts per million - a measurement unit for the sanitizer solution).

During an interview with RD on [DATE REDACTED] at 12:27 p.m., RD stated the dietary staff should have a good knowledge about the manual dishwashing process especially there was an emergency like out of power.

A review of facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated the process involved washing, rinsing, sanitizing, and air-dried, and .sanitizer solution .must read ,d+[DATE REDACTED] ppm .immerse all washed items (in the sanitizer solution) for at least 1 minute (60 seconds) .

5. During a confirmation with DM regarding the storage areas for clean metal pans was not clean with food debris on [DATE REDACTED] at 8:34 a.m., observed DA 2 used a towel to wipe the storage areas. DA 2 stated she used

the towel from the red bucket (bucket contained sanitizer solution) to clean the storage areas.

During an interview with DM on [DATE REDACTED] at 8:45 a.m., DM confirmed DA 2 used the sanitizer to clean the dirty storage areas. He stated the procedure was to sanitize and clean when the food contact surfaces were soiled. Then he switched answer to the correct procedure should be first to clean with soap and water, and then using the sanitizer to sanitize. DM further stated DA 2 did not performed the procedure correctly.

A review of department document titled, Inservice: Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, dated ,d+[DATE REDACTED], indicated, .cleaning and sanitizing of .food contact surfaces .food storage areas are vital in keeping food wholesome and safe to consume .Cleaning is the removal of soils, tarnishes, or stains . Sanitizing is the process of reducing the number of microorganisms on the surface to safe levels so that they cannot cause disease or food spoilage .to be effective, cleaning and sanitizing must be a two-step process. Surface must first be (1) cleaned and rinsed before (2) being sanitized .any surface that comes in contact with food much also be cleaned and sanitized .

6. During an interview with DA 2 on [DATE REDACTED] at 8:34 a.m., DA 2 verbalized the process to prepare and test the sanitizer solution for the red bucket. DA 2 stated she got the pre-mixed sanitizer solution from the dispenser and then used the test strip to test the effective concentration and stated it should be at ,d+[DATE REDACTED] ppm. DA 2 demonstrated to use the test strip by dipping the sanitizer solution for more than 15 seconds and took it out to compare the color chart (different colors from the chart corresponds to different concentration (ppm) range includes: 0, 150, 200, 400 and 500) on the test strip container. Then she used the same test strip to dip in

the sanitizer solution again.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 concurrent confirmation with DM and he stated DA 2 should not dip in the solution again and the test strip should dip in the solution for 10 seconds. DA 2 stated when preparing the sanitizer solution, she usually Level of Harm - Minimal harm or dipped the test strip for more than 10 seconds because the color would not change. She stated the solution potential for actual harm should be cold. The solution was cold when touched and then took the temperature with thermometer and it read 59.7 degrees Fahrenheit (F). Residents Affected - Many DM verified and stated the sanitizer solution should be cold and stated 59.7 degrees F was fine. A concurrent review of the instruction on the test strip container, and it stated, .dip paper (test strip) in quat (sanitizer) solution, not from surface, for 10 seconds .testing solution should be between ,d+[DATE REDACTED] degrees F . DM stated he was not aware of the temperature range of the sanitizer solution, and he would contact the sanitizer vendor to adjust the temperature.

A review of facility P&P titled, Quaternary Ammonium Log Policy, dated 2023, indicated, .Read instructions

on quaternary container and the test strip for proper concentration length of time the strip needs to be in contact with the solution, and if temperature of the solution is to be considered when testing for concentration .Follow container and test strip instructions. A high concentration may potentially hazardous and may be a chemical contaminate of food.

7. During a kitchen inspection tour on [DATE REDACTED] at 10:55 a.m., it was noted DA 3 had a cap on (without any hairnet under the cap) but did not completely cover all his hair. Observed the back of his hair and the side burns on both sides extending outside the cap. A concurrent confirmation with DM and he agreed DA 3's cap did not cover all his hair. DM stated DA 3 should put the hairnet on to completely cover his hair before putting his cap on.

A review of facility P&P titled, Dress Code, dated 2023, indicated, .Hat for hair, if hair is short, which completely covers the hair .Hair net for hair, if hair is long (over the ears or longer) .

8. An observation and a concurrent interview with Licensed Vocation Nurse (LVN) 1 regarding the resident's food refrigerator located at nurse station on [DATE REDACTED] at 2:41 p.m. was conducted.

It was noted there were issues found as followed:

- The interior of the refrigerator was not clean with dry liquid spills on the bottom of shelf (confirmed with LVN 1 and stated it was dirty)

- An opened bag of individual wrapped ice cream cups in the freezer (confirmed with LVN 1 and stated it had no name and received date and should discard)

- An opened box of individual wrapped ice cream sandwiches in the freezer (confirmed with LVN 1 and stated it had no resident's name and the manufacture's expired date of [DATE REDACTED] and should discard)

- A tub of chocolate ice cream in the freezer (confirmed with LVN 1 and stated it had resident's name but no received date, stated should discard)

- A bag with a popsicle in the freezer (confirmed with LVN 1 and stated it had name but no received date, should discard)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 half-drank drink in paper cup in the freezer (confirmed with LVN 1 and stated it had name but no received date, and needed to be discarded) Level of Harm - Minimal harm or potential for actual harm LVN 1 stated the nurses were responsible to monitor temperature and food of the refrigerator. She further stated the nurses who monitor the refrigerator also responsible to clean the refrigerator. She stated there Residents Affected - Many was no set schedule for the refrigerator to be clean. LVN 1 explained the process of when they received food from the residents' families or visitors, the nurses should label the food with resident's name and received date, and the food would be discarded on the third day from the received date and it also applied to the frozen food.

During an interview with LVN 2 on [DATE REDACTED] at 2:29 p.m., LVN 2 stated the process of receiving food from the family or visitor. He stated the nurses usually put the label on the food with resident's name, room number and received date. LVN 2 stated the food could keep in the refrigerator for three days. He stated he was the PM (post meridiem-after midday) nurse and responsible to monitor the refrigerator at PM shift. He further stated the nurses who monitor the refrigerator also responsible to clean the refrigerator. He stated the housekeeping sometimes would clean the refrigerator too but not sure how often.

During an interview with housekeeping (HK) on [DATE REDACTED] at 3:05 p.m., HK stated housekeeping was not responsible to clean the resident's food refrigerator.

During an interview with Director of Nursing (DON) on [DATE REDACTED] at 3:15 p.m., DON acknowledged the issues found in the resident's food refrigerator. DON stated she was not sure how often the resident's food refrigerator getting clean by the nurses. She further stated may be once a week and deep clean every three months.

A review of facility P&P titled, Foods Brought by Family/Visitors, revised ,d+[DATE REDACTED], indicated, .Perishable foods are stored in re-sealed containers with tightly fitting lids in a refrigerator. Containers are labeled with

the resident's name, the room number and the use by date .Perishable foods .may be refrigerated for up to 3 days, then will be discarded by staff .

A review of facility P&P titled, Refrigerators and Freezers, revised ,d+[DATE REDACTED], indicated, .Supervisors are responsible for ensuring food items in .refrigerators, and freezers are not past use by or expiration dates . Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing by designated staff .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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** 44946 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper infection control Residents Affected - Some practices were implemented when:

1. Oxygen tubing was on the floor for Resident 18, Resident 12 and Resident 36.

2. Resident 10's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was dragging on the floor while on the wheelchair.

3. Tube feeding formula was left uncapped and open to air while disconnected from Resident 45.

These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses.

Findings:

1. During a review of Resident 18's Admission Record (AR), the AR indicated, Resident 18 was admitted on [DATE REDACTED] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation (COPD-a chronic lung disease causing difficulty in breathing), acute respiratory failure with hypoxia (when lungs suddenly can't get enough oxygen into the blood) and asthma (condition in which airways narrow and swell).

During a review of Resident 18's Order Summary Report (OSR), printed on 3/12/25, the OSR indicated, Resident 18 had an order for oxygen at 2 liters (unit of measurement) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every 8 hours as needed for SOB (shortness of breath), chest pain, O2 sat (oxygen saturation-measurement of how much oxygen the blood is carrying as a percentage); Notify MD if O2 sat <90%.

During a review of Resident 12's AR, the AR indicated, Resident 12 was admitted on [DATE REDACTED] with diagnoses which included acute respiratory failure with hypercapnia (condition that occurs when the lungs can't get rid of enough carbon dioxide from the blood) and COPD.

During a review of Resident 12's OSR, printed on 3/12/25, the OSR indicated, Resident 12 had an order for continuous O2 (oxygen) at 4 LPM (liters per minute) via nasal cannula to maintain O2 sat >90%.

During a review of Resident 36's AR, the AR indicated, Resident 36 was admitted on [DATE REDACTED] with diagnoses which included acute and chronic respiratory failure with hypoxia and pleural effusion (buildup of fluid between the tissues that line the lungs and the chest).

During a review of Resident 36's OSR, printed on 3/14/25, the OSR indicated, Resident 36 had an order oxygen at 2 L/Min via nasal cannula routine/continuous.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 During a concurrent observation and interview on 3/11/25 at 8:41 a.m. with Licensed Nurse (LN) 1 in Resident 36's room, Resident 36 was lying on the bed with oxygen in use, and the oxygen tubing was Level of Harm - Minimal harm or touching the floor. LN 1 confirmed that the oxygen tubing was on the floor and stated it should not be potential for actual harm touching the floor due to infection control and safety concerns.

Residents Affected - Some During a concurrent observation and interview on 3/11/25 at 9:08 a.m. with LN 6 in Resident 12's room, Resident 12 was lying on the bed with oxygen in use, LN 6 confirmed that the oxygen tubing was on the floor.

During a concurrent observation and interview on 3/11/24 at 9:40 a.m. with Director of Nursing (DON) in Resident 18's room, Resident 18 was sitting up on bed with oxygen in use, DON confirmed the oxygen tubing was on the floor and should not be touching the floor due to infection control concerns.

During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items, Surfaces and Equipment, dated October 2021, the P&P indicated, Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g. respiratory therapy equipment) . such devices should be free from all microorganisms .

2. During a review of Resident 10's AR, the AR indicated, Resident 10 was admitted on [DATE REDACTED] with diagnoses which included acute pyelonephritis (bacterial infection causing inflammation of kidneys, a complication of an ascending urinary tract infection), uterovaginal prolapse (the womb or other pelvic organs dropping down and pressing into the vaginal area), neuromuscular dysfunction of the bladder (the nerves and muscles that control urination aren't working properly), acute cystitis without hematuria (sudden bladder infection that's not causing blood in urine).

During a review of Resident 10's OSR, printed on 3/12/25, the OSR indicated Resident 10 had an order for Foley catheter (a type of urinary catheter) Fr 16 (French 16-size of catheter) vol (volume) 10.

During a concurrent observation and interview on 3/11/25 at 12:26 p.m., with LN 3 in the dining room, Resident 10 was wheeling herself in the wheelchair. LN 3 confirmed the catheter tubing was dragging on the floor and stated that it should not be touching the floor due to infection control concerns.

During a concurrent observation and interview on 3/11/25 at 12:28 p.m., with DON in the nursing station, Resident 10 was in front of the nursing station when the DON checked the catheter tubing and confirmed it was touching the floor. The DON stated that the expectation is for the catheter tubing not to drag on the floor.

During an interview on 3/12/25 at 1:00 p.m., with DON, DON stated the expectation is for oxygen tubing and catheter tubing not to touch the floor and that they follow standard nursing practices for infection control.

During an interview on 3/13/25 at 10:57 a.m., with Infection Preventionist (IP), IP stated that oxygen and catheter tubing should be kept off the floor because touching the floor increases the risk of contamination and the floor can be a source of bacteria.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 555333 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 555333 B. Wing 03/14/2025

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

Lincoln Meadows Care Center 1550 Third Street Lincoln, CA 95648

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 During a concurrent interview and record review on 3/14/25 at 8:49 a.m., with IP, the facility's P&P titled, Indwelling Catheters, dated September 2021 was reviewed. The P&P indicated, Be sure catheter tubing and Level of Harm - Minimal harm or drainage bag are kept off the floor. IP confirmed that this is the policy in her infection control binder and is the potential for actual harm policy she uses to teach staff about infection control practices for urinary catheters.

Residents Affected - Some 50517

3.

During a review of Resident 45's AR, the AR indicated, Resident 45 was admitted [DATE REDACTED] with diagnoses including malignant neoplasm (cancerous/ abnormal growth tissue) lower third of esophagus (muscular tube through which food passes from the throat to the stomach), artificial opening of gastrointestinal tract (feeding tube placement).

During a review of Resident 45's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated, 1/16/25 indicated Resident 45 had mild cognition impairment. Resident 45's Physician Orders indicated, NPO (nothing by mouth), and Enteral feeding (tube feeding), continuous.

During a review of Resident 45's care plan, dated 1/9/25 indicated, resident will not have any complications with feeding tube. The care plan interventions indicated, observe signs and symptoms of infection.

During a concurrent observation and interview on, 3/11/25 at 12:30 p.m., in Resident 45's room, Resident 45 arrived from physical therapy with tube feeding disconnected. Feeding formula (liquified food) was observed hanging on feeding tube pole, with tubing left hanging from pole uncapped and was open to air. LN 4 confirmed that the tubing was left uncapped and stated, leaving a tube feeding formula open to air can lead to a potential infection and contamination especially for residents who are vulnerable.

During a review of the facility's P&P titled, Enteral Feedings, reviewed August 2024, indicated, .preventing contamination maintain aseptic technique use closed enteral nutrition systems when possible.

During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care items, Surfaces and Equipment, revised October 2021 indicated, Critical items consist of items that carry a high risk of infection if contaminated with any microorganism . Objects that enter sterile tissue or vascular system are considered critical items .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 555333