Saylor Lane Healthcare Center

F-F812, #7).

These failures had the potential to place 31 out of 33 highly susceptible residents who consumed food from

the facility kitchen at risk for food borne illness.

Findings:

1. An interview with DA 1 and Dietary Manager (DM) regarding manual dishwashing by using the 2-compartment sink on 5/5/25 at 10:14 a.m. was conducted. DA 1 stated the steps for the 2-compartment sink manual dishwashing were rinse, wash, and sanitize. DA 1 was not sure of the water temperature of the wash and rinse steps, the immersion time for the dishes in the sanitizer, and the correct concentration of the sanitizer. DM prompted DA 1 for the answers by using the posted instructions on the wall. Confirmed with DM and he agreed the staff, especially the dishwasher, needed to have good knowledge about the procedure for manual dishwashing.

During an interview with DA 2 on 5/6/25 at 9:26 a.m., DA 2 stated the process of 2-compartment sink manual dishwashing involved washing, rinsing, and sanitizing. DA 2 stated the water temperatures for the wash and rinse steps were 120 degrees Fahrenheit (F). She stated the immersion time for the dishes in the sanitizer was 20 seconds, and the concentration of the sanitizer was 50 ppm.

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated the staff should have a good knowledge about manual dishwashing because the procedure replaced the dishwashing machine if not working in case of emergency.

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 200 ppm . immerse all washed items (in the sanitizer solution) for at least 60 seconds .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 2. An observation and concurrent interview with DA 2 on 5/6/25 at 9:20 a.m. for the process of dishwashing by the machine was conducted. DA 2 stated the washing and rinsing water temperatures should be 120-140 Level of Harm - Minimal harm or degrees F. She demonstrated the process with the machine and the final temperature for the washing cycle potential for actual harm was 125 degrees F, and the rinsing cycle was 127 degrees F. DA 2 was not able to state the method to show

the effectiveness of the sanitizer of the dishwashing. DA 2 stated using the test strip to test the concentration Residents Affected - Some of the sanitizer with prompt. She was not able to answer the correct concentration of the sanitizer. DA 2 demonstrated using the test strip to test the concentration level. She dipped the test strip in the sanitizer

during the washing cycle, and the test strip did not register any color (the change of color shows the levels of concentration of the sanitizer). Then she used the same test strip to test three times until the color was changed. By prompt, she used the new test strip to test again after the washing and rinsing cycles were completed. The test strip showed the concentration was 50 ppm (parts per million - a measurement unit for

the concentration of the sanitizer), but she stated the concentration should be 200 ppm.

During an interview with RD on 5/6/25 at 3:29 p.m., RD acknowledged the issue above and stated the staff, especially dishwashers, should be able to know the dishwashing procedure which the dishes would be washed and sanitized properly to avoid food borne illness.

A review of facility P&P titled, Dishwashing, dated 2023, indicated, .the Chlorine (sanitizer for dishwashing machine) should read 50-100 ppm on dish surface in final rinse (after the wash and rinse cycles). The proper chorine level is crucial in sanitizing the dishes .

A review of the test strip vial with instruction, it stated, .to remove strip of paper from vial, dip strip into solution to be tested , without agitation and compare immediately with color chart on label. This color indicates approximate strength of the solution in parts per million (ppm) available chlorine. Time for test 1 second . There were four different colors that indicated different levels of concentration with 10 ppm, 50 ppm, 100 ppm, and 200 ppm.

A review of job description of dietary aides, dated 6/2020, it indicated dietary aides should .perform dishwashing/cleaning procedures .prepare food, etc., in accordance with sanitary regulations as well as with our established policies and procedures .ensure that the department is maintained in a clean and safe manner .

A review of DA 1's employee file with his date of hire (DOH) was on 1/9/25 for the dietary aide position. The document titled, Verification of Job Competency Demonstration - Dietary Aides, completed for the year of 2025 by DM, indicated DA 1 was competent on the category, Emergency dish washing procedure and when to use it. An interview with DM on 5/7/25 at 10:06 a.m., DM confirmed and stated DA 1 was competent on

the emergency dish washing procedure.

A review of DA 2's employee file with her DOH was on 4/21/20 for the dietary aide position. The document titled, Verification of Job Competency Demonstration - Dietary Aides, completed for the year of 2025 by DM, indicated DA 2 was competent on the categories of Sanitation method used in dish machine and proper concentration and Emergency dish washing procedure and when to use it. It indicated DA 2 was competent for both categories with verbal and demonstration methods.

A review of departmental document titled, Food and Nutrition Services In-Service, Topic: 3-compartment sink, completed on 3/3/2025, given by DM, indicated DA 1 and DA 2 attended.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 departmental document titled, Food and Nutrition Service In-Service, Topic: Dishwashing Machine, completed on 2/17/25, given by DM, indicated DA 2 attended. Level of Harm - Minimal harm or potential for actual harm A review of job description of dietary manager, dated 6/2020, it indicated the DM should, .shall oversee facility .assist in the development of an participate in the planning, conducting, .in-service training classes Residents Affected - Some that provide instructions on how to do the job, and that ensure a well-educated food services department . monitor food services service personnel to assure that they are following established safety regulations in the use of equipment and supplies .ensure that all food services service personnel follow established departmental policies and procedures .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 - Some Based on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet during lunch on 5/6/25 when:

1. Five residents (Resident 1, 8, 10, 19 and 139) with mechanical soft (MS) texture diets (a diet consisting of soft, moist foods for people who have chewing and/or swallowing difficulties) received a smaller portion of mechanical soft meatballs.

2. Resident 16 with fortified diets (added calories and/or protein) did not get fortified foods with Resident 16's meal.

These failures had the potential to result in compromising the medical and nutrition status of 6 out of 31 residents who received meals from the facility kitchen.

Findings:

During the lunch meal distribution on 5/6/25 beginning at 12:05 p.m., it was noted as follows:

1. During an interview with [NAME] (CK) on 5/6/25 at 9:37 a.m. before meal distribution started, CK stated

the fortified foods for lunch on 5/6/25 were to give extra one ounce (oz.) of gravy on the meat and extra 1/2 oz. of melted margarine on the vegetables.

Resident 16 with fortified diet did not receive extra one oz. of gravy on the meatballs and extra 1/2 oz. of melted margarine on the vegetables.

2. Five residents (1, 8, 10, 19 and 139) with MS texture diets received two oz. (#16 scoop

of MS meatballs.

During an interview with CK on 5/6/25 at 12:34 p.m., CK confirmed and stated he used #16 scoop (two oz.) to serve the MS meatballs for the residents with MS texture diets. 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 Tuesday, indicated that MS texture diet should receive #10 scoop (three oz.) of MS meatballs.

During an interview with Registered Dietitian (RD) on 5/6/25 at 3:29 p.m., RD acknowledged the issues found above during the meal distribution. She stated the staff, or CK should follow the fortification as indicated in the spreadsheet. She further explained the fortified food provided extra calories to the residents who needed the extra nutrition. If the fortified foods were not provided, those who needed them may lead to at risk of weight loss.

RD stated the CK needed to follow the spreadsheet to provide the correct portion (scoop) size for the food to

the residents. RD further stated providing the wrong portion size of the meat may affect wound healing and/or limit the protein for the residents to meet their protein need.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 facility policy and procedures titled, Menu Planning, dated 2023, indicated, .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Level of Harm - Minimal harm or Physician's orders . potential for actual harm

A review of the facility document titled, Dietary Supervisor - Job Duties and Responsibilities, dated 6/2020, Residents Affected - Some indicated the therapeutic and regular diets and menus should be followed per the physician's orders.

A review of facility document titled, Job Description: Cook, dated 9/1/23, indicated, .Essential job functions . follow recipes and prepares foods that correspond to menu cycles and recipes .Inspect trays following meal service to monitor and record resident acceptance of menu items .able to understand and to follow written and verbal directions including menus, tray tickets .

A review of facility document titled, Dietary Aide-Job Duties and Responsibilities, dated 1/10/2025, indicated, . Food services .served food in accordance with established portion control procedures .assist in checking diet trays before distribution .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 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 safety when:

1. The ice machine was not clean per manufacturer's guidance,

2. The reach-in freezer was not clean,

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

4. The cutting boards had deep grooves,

5. Several metal pans were stacked wet and stored in the clean and ready-to-use storage areas,

6. Dietary Aide (DA) 1 and DA 2 were unable to verbalize the proper procedure of manual dishwashing with

the 2-compartment sink,

7. DA 2 was unable to verbalize and demonstrate the proper testing and correct concentration of the sanitizer for the dishwashing with the dishwashing machine and

8. DA 3 was noted with long artificial nails with gem decor.

These failures had the potential to cause food contamination which could cause food borne illnesses for 31 out of 31 medically vulnerable residents who consumed food from the facility kitchen.

Findings:

1. During an observation and concurrent interview with Maintenance Supervisor (MS) on 5/6/25 at 11 a.m., MS stated he was responsible for doing deep cleaning (cleaning and sanitizing the machinery parts on the top section of the ice machine and ice storage bin on the bottom section of the machine with chemical solutions designed to remove lime scale and mineral deposits and to remove algae and slime, then sanitize with chemical agent) of the ice machine monthly. He stated the last deep cleaning was completed on 4/17/25. He further stated the water filter was changed every six months.

MS dissembled the top (machinery) part of the ice machine; it was noted there were black substances on the inside of the water curtain (a plastic cover rest on the ice making panel to redirect the ice to the ice storage bin), and the substances could be removed when wiping with paper towel. The water trough (a plastic tray under the evaporator unit) was detached and observed there were pink substances on the side and could be removed when wiping the paper towel. There were significant black substances found on the bottom of the evaporator unit (a unit where to make ice). The black substances were hard to remove by wiping with paper towel and were rough to touch. MS confirmed the findings and agreed the ice machine was dirty.

MS explained the deep cleaning steps of the ice machine as followed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 1. Discard the ice from the ice storage bin,

Level of Harm - Minimal harm or 2. Dissemble the removable components (water curtain and water trough) to clean with descaler (cleaner) potential for actual harm solution and then sanitize them with sanitizer (MS stated the water level probe and the ice thickness probe could not be removed, therefore, he did not dissemble them to clean and sanitize.), Residents Affected - Many 3. Use the descaler and sanitizer to clean and sanitize the components, wall and ice storage bin,

4. Assemble the parts (water curtain and water trough) together,

5. Pour the descaler solution in the water reservoir and run the cleaning cycle (MS confirmed and stated he only used the descaler to run the cleaning cycle, and he stated No, when asked if he used any other solution to run different kind of cycle.) and

6. After the cleaning cycle is done, turn on ice mode to start making ice. Discard the first batch of ice, and the second batch would be ready to use.

During an interview with Registered Dietitian (RD) on 5/6/25 at 3:29 p.m., RD stated the ice machine needed to be cleaned to prevent bacteria or other dirt getting into the ice that may possibly cause food borne illness.

A review of [Manufacturer's Name] Ice Machines Installation, Operation and Maintenance Manual, dated 2/2020, indicated, .Ice machine cleaner/descaler is used to remove lime scale and mineral deposits .sanitizer disinfects and removes algae and slime .Parts removal for detailed descaling and sanitizing .remove the water curtain .remove the ice thickness probe .remove water trough .remove the water level probe .remove

the water distribution tube(s) . It further indicated when cleaning and sanitizing needed to pay attention to the following areas: side walls, base (area above water trough), evaporator plastic parts (including top, bottom and sides), and the ice storage bin. The ice machine needed to run the cleaning cycle with descaler solution and then run the sanitizing cycle with sanitizer solution after the components put back together.

A review of facility policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2023, indicated, .the ice machine needs to be cleaned and sanitized monthly .the internal components cleaned monthly .Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual .

According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 In addition, on Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and Level of Harm - Minimal harm or accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential potential for actual harm harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release Residents Affected - Many pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits .

2. During an observation of the reach-in freezer on 5/5/25 at 9:13 a.m., it was noted there were brown liquid spills on the top of the freezer, the top shelf, on the card board boxes on the middle shelf, on the bottom of

the freezer, and the spill splashed on the freezer door. The liquid spills were sticky when touched and able to remove by wiping using paper towel.

During an interview with [NAME] (CK) on 5/5/25 at 9:25 a.m., CK confirmed and stated the spills and splashes were from the explosion of the soda can. He further stated the staff usually would clean up spills immediately and the staff checked the cleanliness every morning and evening.

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated the freezer should be clean with no spills. She further stated the staff should clean up the spills immediately.

A review of facility P&P titled, Refrigerator and Freezer, dated 2023, indicated, .Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods .wipe up spills immediately .

3. During the kitchen observation and a concurrent interview with CK on 5/5/25 at 9:41 a.m., it was noted that

the blade of the can opener had discoloration and the blade surface metal part worn off. CK confirmed and stated the blade was old and needed to be replaced. He further stated the metal worn off could potentially lead to physical contamination and that the piece of metal may fall into the food.

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 .

4. During the kitchen observation and a concurrent interview with CK on 5/5/25 at 9:30 a.m., it was noted two cutting boards (red and brown color coded) with significant deep grooves on the surfaces. CK confirmed and stated the cutting boards were old and should be replaced.

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated the boards with deep grooves needed to be replaced. She further stated the deep grooves made the boards hard to clean and may trap food or bacteria that cause contamination.

A review of undated facility P&P titled, Cutting Board Maintenance Policy and Procedure, indicated, . Inspection and Replacement .cutting boards must be inspected for deep grooves, stains, warping, or cracking .boards that cannot be fully cleaned or have significant surface damage must be removed from service and replaced immediately .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 5. During the kitchen inspection and a concurrent interview with CK on 5/5/25 at 9:38 a.m., it was noted there were six full sheet metal pans that were stacked wet and stored in the clean and ready-to-use storage areas. Level of Harm - Minimal harm or CK confirmed and stated the pans and dishes needed to be completely air-dried before stored away. potential for actual harm

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated the dishes and pans need to be air-dried Residents Affected - Many before stored away to prevent bacteria growth.

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

6. DA 1 and DA 2 were unable to verbalize the proper procedure of manual dishwashing by the 2-compartment sink when:

a. During an interview with DA 1 and Dietary Manager (DM) on 5/5/25 at 10:14 a.m., DA 1 stated if the dishwashing machine was not working, he would switch to manual dishwashing with the 2-Compartment sink. DA 1 stated first he would soak the dishes, then the following steps were rinse, wash and sanitize, he repeated the same steps three times when asked for confirmation. DA 1 was not sure of the water temperature for the wash and rinse steps. DM cued DA 1 with the posted manual dishwashing instruction on

the wall and DA 1 stated the temperature should be at least 110 degrees Fahrenheit (F). DA 1 could not answer the immersion time for the dishes in the sanitizer. DM cued DA 1 again with the posted instruction and DA 1 stated the immersion time should be 60 seconds. DA 1 did not know the correct concentration of

the sanitizer until DM 1 cued him to read the poster and DA 1 stated 200 ppm (parts per million - a measurement unit for the sanitizer solution).

Confirmed with DM and he agreed the staff, especially the dishwasher, needed to have good knowledge about the procedure for manual dishwashing.

b. During an interview with DA 2 on 5/6/25 at 9:26 a.m., DA 2 stated she would start to use the 2-Compartment sink for dishwashing when the dishwashing machine was not working. DA 2 stated the steps were to wash, rinse and sanitize. She stated the water temperatures for the wash and rinse steps were 120 degrees F. DA 2 stated she used a big tub served as the third compartment for the sanitizer solution for the sanitizing step and the immersion time of the dishes was 20 seconds. She stated by using the test strip to check the concentration of the sanitizer and the correct concentration should be 50 ppm.

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated the staff should have a good knowledge about manual dishwashing because the procedure replaced the dishwashing machine if not working in case of emergency.

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 200 ppm . immerse all washed items (in the sanitizer solution) for at least 60 seconds .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 7. During an observation and concurrent interview with DA 2 on 5/6/25 at 9:20 a.m., DA 2 verbalized and demonstrated the process of dishwashing by the machine. DA 2 stated the temperatures for the washing and Level of Harm - Minimal harm or rinsing cycles in the dishwashing machine were 120-140 degrees F. She demonstrated the process with the potential for actual harm machine and the final temperature for the washing cycle was 125 degrees F and the rinsing cycle was 127 degrees F. Residents Affected - Many DA 2 could not answer when asked how she ensured if the sanitizer was effective during dishwashing with

the machine. She stated that by using the test strip to test the concentration of the sanitizer with prompt. She could not answer the correct concentration of the sanitizer for testing by using the test strip. DA 2 demonstrated using the test strip to test the concentration level. She used the test strip to test the concentration during the washing cycle and the test strip did not register any color (the change of color shows the levels of concentration of the sanitizer). Then she used the same test strip to test three times until

the color was changed. Then she used the new strip by cueing to test again after the washing and rinsing cycles were completed. The test strip showed the concentration was 50 ppm, but DA 2 stated the concentration should be 200 ppm.

During an interview with RD on 5/6/25 at 3:29 p.m., RD acknowledged the issue above and stated the staff, especially dishwashers, should be able to know the dishwashing procedure which the dishes would be washed and sanitized properly to avoid food borne illness.

A review of facility P&P titled, Dishwashing, dated 2023, indicated, .the Chlorine (sanitizer for dishwashing machine) should read 50-100 ppm on dish surface in final rinse (after the wash and rinse cycles). The proper chorine level is crucial in sanitizing the dishes .

A review of the test strip vial with instruction, it stated, .to remove strip of paper from vial, dip strip into solution to be tested , without agitation and compare immediately with color chart on label. This color indicates approximate strength of the solution in parts per million (ppm) available chlorine. Time for test 1 second . There were four different colors indicating different levels of concentration with 10 ppm, 50 ppm, 100 ppm, and 200 ppm.

8. During the kitchen inspection on 5/6/25 at 9:17 a.m., it was noted DA 3 had long (approximately one inch) artificial nail with gems decor. Observed DA 3 was using bare hands to touch the food contact surfaces of

the pans, clean dishes from the clean side of the dishwashing machine, and the ready-to-use utensils at 10:24 a.m., 11:25 a.m., and 11:35 a.m. respectively.

During an interview with DM on 5/6/25 at 12:56 p.m., DM acknowledged and stated the long artificial nails were not acceptable and DA 3 should not have artificial nails, and the nails should be trimmed.

During an interview with RD on 5/6/25 at 3:29 p.m., RD stated she preferred the kitchen staff to keep their fingernails short and trimmed. She further stated the artificial nails, and the gems decor had potential to fall into the food and cause contamination.

A review of facility P&P titled, Dress Code, dated 2023, indicated, .fingernails kept short and well groomed . no nail polish .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 According to Food and Drug Administration (FDA) Food Code 2022, Section 2-302.11 Maintenance, indicated, (A). Food Employees shall keep their fingernails trimmed, filed, and maintained so the edges and Level of Harm - Minimal harm or surfaces are cleanable and not rough .(B) Unless wearing intact gloves in good repair, a food employee may potential for actual harm not wear fingernail polish or artificial fingernails when working with exposed food .

Residents Affected - Many In addition, on Section 2-301.12 Cleaning Procedure, indicated, .the greatest concentration of microbes exists around and under the fingernails of the hands .The area under the fingernails .by far the largest concentration of microbes on the hand and it is also the most difficult area of the hand to decontaminate .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 40830 potential for actual harm Based on observation, interview and record review, the facility failed to provide a clean environment for the Residents Affected - Many residents and visitors when one out of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids.

This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Findings:

During a concurrent observation and interview with [NAME] (CK) on 5/5/25 at 9:44 a.m., observed one out of one dumpster was covered with its two lids. However, the lids were bowed away from the edge of the dumpster and leaving a one- to two-inch gap in between. The deformed lids lacked the integrity to securely cover the bin. There were a few bags of trash with few flies flying around the trash inside the dumpster observed. CK confirmed and stated the lids needed to close tightly and agreed the lids were deformed. He further stated the dumpster should be closed tightly with its lids. CK stated he would call the waste management company to get new replacement.

During an interview with Registered Dietitian (RD) on 5/6/25 at 3:29 p.m., RD stated the dumpster needed to be closed or sealed tightly with the lids to prevent rodents getting in the dumpster.

A review of undated facility policy and procedure titled, Trash and Dumpster Management Policy and Procedure, Commercial Kitchen, it indicated, .Dumpster lids must remain closed at all times .Dumpster area inspections should occur weekly and be documented .

According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, referenced 7/23/24, (A) Receptacles and waste handling units for refuse .used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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** 39489 potential for actual harm Based on observation, interview, and record review, the facility failed to follow and maintain an effective Residents Affected - Some infection prevention and control program for a census of 33 residents when:

1. A staff handled resident's food with bare hands;

2. Clean linen touched the floor and touched employee's clothes;

3. Safe infection control practices were not followed for cleaning and disinfecting a shared glucometer (a device used to measure blood sugar) in-between resident care and aseptic technique was not followed

during medication preparation;

4. Nursing staff did not perform hand hygiene when moving from one route of medication administration to another and after handling a contaminated medical device;

5. A facility staff held Resident 15's 5/5/25 lunch meal with bare hands;

6. Resident 3's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) face mask was not changed every seven days;

These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of residents to germs, and may cause infection among residents, staff, and visitors.

Findings:

1. A review of Resident 142's Admission Record, indicated, Resident 142 was admitted to the facility on [DATE REDACTED] with diagnosis that included legal blindness (a level of visual impairment that limits the activities performed by individuals without assistance), need for assistance with personal care and difficulty walking.

A review of Resident 142's MDS Section B - Hearing, Speech, and Vision, indicated, Resident 142 had a score of 4 for vision, which indicated, severely impaired vision.

During a concurrent observation and interview inside the room of Resident 142 with CNA 1 on 5/5/25 at 1:05 p.m., CNA 1 delivered Resident 142's meal tray and assisted him with his lunch. CNA 1 picked up the taco from Resident 142's plate with her bare hands, placed it in Resident 142's hands, instructed him to eat, and Resident 142 ate his taco. CNA 1 acknowledged she held Resident 142's taco with her bare hands. CNA 1 stated she should not hold Resident 142's food with her bare hands to promote infection control.

2. During a concurrent observation and interview inside the clean laundry room with Laundry Aide 1 (LA 1)

on 5/7/25 at 10:42 p.m., as LA 1 was folding the white clean linen, the clean linen touched her clothes and

the floor. LA 1 stated as she clutched the clean linen close to her body, that it was okay for the clean linen to touch her clothes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 an interview with the Housekeeping and Laundry Supervisor (HLS), on 5/7/25 at 9:54 a.m., the HLS stated LA 1's clothes should not touch the clean linen or the floor. The HLS further stated that the floor was Level of Harm - Minimal harm or contaminated, and LA 1 should wash the linens again. potential for actual harm

During an interview with the DON on 5/7/25 at 3:50 p.m., the DON stated, CNA 1 should not hold Resident Residents Affected - Some 142's food with her bare hands as an infection control protocol. The DON also stated that LA 1 should keep

the clean linen away from her clothes and off the floor when folding it to keep it clean. The DON continued, LA 1 should use the laundry basket while folding the clean linens, to keep if off the contaminated/dirty floor.

A review of the facility's policy and procedure, titled Hand Hygiene for Staff Providing Feeding Assistance, undated, indicated, Purpose: To prevent the transmission of infection and ensure safe and sanitary conditions while assisting residents with feeding, by enforcing strict hand hygiene practices among staff .

A review of the facility's policy and procedure, titled Departmental (Environmental Services) - Laundry and Linen revised date January 2014, indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen .

43258

3. During a medication pass observation on 5/5/25 at 11:33 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed measuring Resident 12's blood sugar level with an Evencare G3 glucometer. LN 1 placed the glucometer into a black plastic tray, went into the resident's room, measured the resident's blood sugar then went to clean the glucometer and tray. LN 1 removed one cleaning and disinfecting wipe from the container, then wiped both the tray and the glucometer. LN 1 then prepared Resident 12's insulin lispro (a fast-acting insulin) pen. LN 1 removed the cap from the pen, then attached a needle onto the rubber seal without first sanitizing and disinfecting it.

During a second medication pass observation on 5/5/25 at 11:37 a.m. with LN 1, LN 1 was observed measuring Resident 1's blood sugar with the same glucometer. Once the resident's blood sugar was measured, LN 1 removed one sanitizing and disinfecting wipe from the container and used it to clean both

the black plastic tray used to carry the glucometer and the device itself. LN 1 then prepared Resident 1's insulin lispro pen. LN 1 removed the cap from the pen, then attached a needle onto the rubber seal without first sanitizing and disinfecting it.

During a third medication pass observation on 5/5/25 at 11:48 a.m. with LN 1, LN 1 was observed measuring

a Resident 17's blood sugar with the same glucometer. Afterwards, LN 1 used one wipe to clean the black plastic tray and the glucometer.

During an interview on 5/5/25 at 1:58 p.m. with LN 1, LN 1 stated he was not aware of any special steps taken to clean or disinfect the insulin pen rubber seal prior to placing the needle on. He stated it was a simple process; he would twist off the cap, put the needle on, then dialed the dose. He stated he did not ever wipe

the pen rubber seal with an alcohol pad prior to placing a needle on. LN 1 stated there had not been any training regarding proper sanitizing and disinfecting of blood glucose monitors. He stated nursing staff were to use their judgement to determine if one wipe was adequate for sanitizing and disinfecting multiple surfaces.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 an interview on 5/6/25 at 3:44 p.m. with Director of Nursing (DON), DON stated nursing staff were educated to sanitize and disinfect the glucometers before, after and in-between residents. She stated nursing Level of Harm - Minimal harm or staff were expected to use a new wipe for each type of surface or device that was cleaned. potential for actual harm

A review of an article published by the Centers for Disease Control and Prevention (CDC) titled, Residents Affected - Some Considerations for Blood Glucose Monitoring and Insulin Administration, the article indicated, Recommend practices in healthcare settings . Blood glucose meters . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared.

A review of the operations manual for EvenCare G3's indicated, Cleaning and Disinfecting . Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of

the approved disinfecting wipes .

During a review of the manufacturer's labeling for insulin lispro pen, dated 5/2012, the labeling indicated, Follow these instructions for each injection 1. Preparing the Humalog Kwikpen [brand name for insulin lispro pen] A. Pull Pen Cap to remove B. Remove Paper Tab from Outer Needle Shield. C. Push capped needle straight onto the Pen. Screw needle on until secure . Use an alcohol swab to wipe the Rubber Seal on the end of the Cartridge Holder.

During a review of the facility's policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, the P&P indicated, Steps in the Procedure . 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.

4. During a medication pass observation on 5/6/25 at 8:11 a.m. with LN 2, LN 2 observed preparing and administering medications to Resident 18, including bicalutamide (a hazardous chemotherapeutic medication used to treat prostate cancer) 50 milligrams (mg, a unit of measurement), Breyna (an inhaler to treat asthma) 160/4.5 microgram (mcg, a unit of measurement) inhaler, and Refresh Tears (an eye drop used to lubricate dry eyes) 1% eye drops. LN 2 prepared the medications in separate plastic cups and placed the medications

in a tray that she carried into the Resident 18's room. LN 2 put on gloves to administer the oral medications first, then administered two puffs from the inhaler to the resident. LN 2 used a tissue to wipe the inhaler then administered the resident's eye drops without changing gloves or performing hand hygiene in-between.

During an interview on 5/6/25 at 10:29 a.m. with LN 2, LN 2 stated that best practice during the medication pass for Resident 18 would have been to perform hand hygiene and change gloves between administering

the oral medications and eye medications.

During an interview on 5/6/25 at 3:44 p.m. with DON, DON stated she had educated nursing staff to perform hand hygiene between care for different residents and between administration of medication through different routes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 review of the facility's P&P titled, Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated, Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing at least 62% alcohol; Level of Harm - Minimal harm or or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . k. After potential for actual harm handling used dressings, contaminated equipment, etc.

Residents Affected - Some During a review of the facility's policy P&P, revised 4/2019, the P&P indicated, Policy Interpretation and Implementation . 24. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

47197

5. A review of Resident 15's clinical record indicated Resident 15 was admitted April of 2025 and had diagnoses that included malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), and need for assistance with personal care.

A review of Resident 15's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 4/13/25, indicated Resident 15 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 15 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 15's MDS Functional Abilities, dated 4/13/25, indicated Resident 15 needed setup or clean-up assistance with eating.

During an observation on 5/5/25 at 1:04 p.m. of Resident 15 and Certified Nurse Assistant (CNA) 1, in front of Resident 15's room, CNA 1 was observed assisting Resident 15 with her lunch meal. Resident 15's lunch meal was a vegetarian soft taco. CNA 1 placed the soft tortilla on her bare left hand and proceeded on filling

it up with beans and vegetables using a fork. CNA 1 then held the soft taco with two bare hands and placed it

on Resident 15's plate. CNA 1 was observed to have a small white dressing on the side of her left pointing finger.

During a subsequent interview on 5/5/25 at 1:08 p.m. with Resident 15, in front of Resident 15's room, Resident 15 stated she was not comfortable, and she did not like it when staff handled her taco with her bare hands.

During a subsequent interview on 5/5/25 at 1:12 p.m. with CNA 1, CNA 1 confirmed she held Resident 15's taco meal with her bare hands when she assisted Resident 15 with her meal. CNA 1 also confirmed she had

a small white dressing on the side of her left pointing finger and stated she has a cut on her finger. CNA 1 stated it would be a risk for food contamination if resident's meal is handled with bare hands.

During an interview on 5/7/25 at 11:28 a.m. with the Director of Staff Development (DSD), the DSD stated handling ready-to-eat food such as taco with bare hands would place the resident at risk for infection. The DSD further stated it was okay for CNA 1 to assist residents with their meals as long as her cut was covered.

During an interview on 5/7/25 at 2:49 p.m. with the Director of Nursing (DON), the DON stated she would expect staff to use utensils and observe infection control properly when assisting residents with their meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 3-301.11, titled, Preventing Contamination from Hands, 1/18/23 version, indicated, (B) .FOOD EMPLOYEES may not Level of Harm - Minimal harm or contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as potential for actual harm deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.

Residents Affected - Some A review of the US FDA 2022 Food Code, section 2-401.13, titled, Use of Bandages, Finger Cots, or Finger Stalls, 1/18/23 version, indicated, If used, an impermeable cover such as a bandage .located on the wrist, hand or finger of a FOOD EMPLOYEE working with exposed FOOD shall be covered with a single-use glove.

6. A review of Resident 3's clinical record indicated Resident 3 was admitted April of 2025 and had diagnoses that included congestive heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), pleural effusion (a condition where excessive fluid accumulates in the area between the lungs and the chest wall), and malignant neoplasm (cancer) of pleura (a membrane surrounding the lungs).

A review of Resident 3's MDS Cognitive Patterns, dated 4/18/25, indicated Resident 3 had a BIMS score of 13 out of 15 which indicated Resident 3 had an intact cognition. A review of Resident 3's MDS Health Conditions, dated 4/18/25, indicated Resident 3 experienced shortness of breath or trouble breathing when lying flat.

A review of Resident 3's physician's order, dated 4/24/25, indicated, Ipratropium-Albuterol Inhalation Solution [a combination medication used to treat COPD] 0.5-2.5 (3) MG [milligrams- unit of measurement] /3ML [milliliters- unit of measurement] .3 ml inhale orally every 6 hours for wheezing/SOB [shortness of breath].

During a concurrent observation and interview on 5/5/25 at 10:14 a.m. with Resident 3, in Resident 3's room, Resident 3's nebulizer face mask tubing was labelled 4/12/25. Resident 3 stated she last used her nebulizer

this morning.

During a concurrent observation and interview on 5/5/25 at 10:45 a.m. with Licenses Nurse (LN) 3, in Resident 3's room, LN 3 confirmed that Resident 3's nebulizer face mask tubing was labelled 4/12/25 which was already more than 3 weeks. LN 3 stated Resident 3 uses her nebulizer four times a day. LN 3 stated the face mask tubing should be changed every week for infection control.

During an interview on 5/7/25 at 11:28 a.m. with the DSD, the DSD stated that nebulizer face mask should be changed every seven days because nebulizer is used to deliver medication directly into the lungs. The DSD further stated there would be a risk of infection if the nebulizer face mask was not changed every seven days.

During an interview on 5/7/25 at 2:49 p.m. with the DON, the DON stated she would expect nebulizer face mask to be changed weekly for infection control.

A review of the facility's policy and procedures (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated, 25. Change equipment and tubing every seven days, or according to facility protocol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 39489

Residents Affected - Few Based on interview and record review, the facility failed to document and maintain records of COVID -19 (mild to severe, viral, respiratory infections) vaccination status for seven of 80 facility staff, Licensed Nurse 4 (LN 4), LN 5, Laundry Aide 2 (LA 2), Certified Nursing Assistant 6 (CNA 6), [NAME] 2 (CK 2), CNA 4, and CNA 5.

This deficient practice increased the risk for residents to acquire, transmit, or experience complications from COVID -19 infections, compromising the residents, and the visitor's safety.

Findings:

During a concurrent interview and record review with the Director of Staff Development (DSD) and Infection Control Nurse (IC) on 5/8/25/ at 12:11 p.m., the DSD and IC confirmed they did not find vaccination records for COVID -19 for 7 facility staff in their Employee Records. The DSD stated they offered immunizations such as COVID -19 to the newly hired employees during their first day of orientation in the facility. The DSD searched the Employee Records and did not find documentation of COVID -19 vaccination status for the following facility staff:

1. LN 4, date of hire 9/3/24;

2. LN 5, date of hire 1/14/25;

3. LA 2, date of hire 1/24/25;

4. CNA 6, date of hire 4/17/25;

5. CK 2, date of hire 4/13/23;

6. CNA 4, date of hire 4/1/25; and

7. CNA 5, date of hire 1/4/25.

During an interview with the Administrator on 5/8/25 at 12:25 p.m., the Administrator stated the facility supported and encouraged employees to get immunized with the COVID -19 vaccine for everyone's safety.

During an interview with the Nurse Consultant (NC) on 5/8/25 at 12:39 p.m., the NC stated it was recommended for the facility staff to get immunized with COVID -19 to prevent potential risk of respiratory infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 055417 Department of Health & Human Services Printed: 08/27/2025 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 055417 B. Wing 05/08/2025

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

Saylor Lane Healthcare Center 3500 Folsom Boulevard Sacramento, CA 95816

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 0887 In a review of the facility's policy and procedure titled, Employee Infection and Vaccination Status, Revision Date, January 2024, indicated, Prior to or upon an employee's duty assignment, the facility will assess the Level of Harm - Minimal harm or status of an employee's vaccination against infectious conditions, screening for tuberculosis, and recent potential for actual harm history of communicable diseases . and vaccinations are documented on the Employee Record of Vaccination . 1. Employees will be current with mandated vaccinations prior to performing direct resident Residents Affected - Few care .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 055417