Health inspection·October 1, 2024

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide food that was palatable when three of seven sampled residents (Resident 3, Resident 4, and Resident 7) had food that was served cold. Residents Affected - Some This failure had the potential for Resident 3, Resident 4, and Resident 7 to experience dissatisfaction with meals leading to decreased intake with possible weight loss. Findings: A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in March 2023 with multiple diagnoses including hemiparesis (weakness on one side of the body) and hemiplegia (paralysis on one side of the body) following cerebral infarction (stroke- lack of blood flow to the brain) and moderate protein calorie malnutrition (inadequate intake of protein, calories, and nutrients). A review of Resident 3's MDS (Minimum Data Set- a federally mandated assessement tool), Cognitive Patterns, dated 9/18/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 3 was cognitively intact. A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in October 2021 with multiple diagnoses including osteoarthritis (type of arthritis caused by the wearing down of cartilage that lines the joints) of left knee and moderate protein calorie malnutrition. A review of Resident 4's Minimum Data Set MDS, Cognitive Patterns, dated 8/2/24, indicated Resident 4 had a BIMS score of 14 out of 15 that indicated Resident 4 was cognitively intact. A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility in September 2024 with multiple diagnoses including hemiparesis and hemiplegia following cerebral infarction and diabetes (too much sugar in the blood). A review of Resident 7's MDS, Cognitive Patterns, dated 9/12/24, indicated Resident 7 had a BIMS score of 13 out of 15 that indicated Resident 7 was cognitively intact. A review of Resident 7's Resident Grievance Form, dated 9/18/24, indicated .Resident verbalized concerns about the food. She states food tray comes to her cold. Last night dinner looks like dog food, fried eggs cold for breakfast .Investigation Findings: Counseled staff on making sure food is covered so that it stays hot. Also counseled on plating/ presentation . Page 1 of 3 055446 055446 10/01/2024 Rock Creek Care Center 260 Racetrack Street Auburn, CA 95603

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Summer and Fall Menus, from 8/5/24 to 10/1/24, with site for temperature entries of menu items, indicated multiple missing temperature entries including: 8/5/24, 8/8/24, 8/9/24, 8/14/24, and 8/17/24, the dinner temperature entries were missing, 8/6/24, 8/11/24, 8/12/24, and 8/13/24, menu items including rice, zucchini, sweet potato fries, and breakfast meat, were missing temperature entries. Menu spreadsheets for 8/15/24 and 8/18/24 did not have temperature entries, and there were no menu spreadsheets for 9/2/24 to 9/5/24 and 9/13/24 to 9/30/24. During an interview on 10/1/24 at 12:20 p.m. with the Dietary Manager (DM), the DM stated she recently started working at facility and has not heard any complaints about food temperature, but has heard complaints about how food looks. The DM stated she checked food temperatures today at point of service from kitchen but did not check temperature of food when served to residents. The DM stated the Certified Nursing Assistants (CNAs) pass out meal trays to the residents. During an interview on 10/1/24 at 1:28 pm. with Resident 3, Resident 3 stated her breakfast yesterday was cold. Resident 3 stated she asked to have it reheated but was told it could not be reheated. Resident stated food is cold off and on. During an interview on 10/1/24 at 1:34 p.m. with Resident 4, Resident 4 stated food is always cold. Resident stated the vegetables are cold. Resident 4 stated she is not eating well. During a joint interview on 10/1/24 at 2:10 p.m. with the Director of Nursing (DON) and the Social Services Director (SSD), the DON stated if resident complains of cold food will have the kitchen make a new tray. The CNAs deliver the food to the residents and are to close the cart door each time trays are pulled out. The DON stated the Registered Dietitian (RD) performs test tray temperature checks. Requested documentation of test tray temperature checks. During an interview on 10/1/24 at 2:12 p.m. with Licensed Nurse (LN) 1, LN 1 stated, Cold food has been an issue. LN 1 stated for the past couple of weeks residents have complained of the protein being cold. During an interview on 10/1/24 at 2:18 p.m. with the DM, the DM stated the cook takes the temperature of food on the steam table and records it on the menu. The DM provided menus for 8/5/24 to 8/17/24, and acknowledged that temperature recordings were incomplete. The DM stated she was unable to locate the menus for 8/18/24 to 9/30/24 but will check with the cook. The DM stated the prior cook was not recording the temperatures on the menus. During a subsequent interview on 10/1/24 at 2:36 p.m. with the DM, the DM stated that there is not a test tray temperature log and did not know to maintain one. The DM stated she had been testing temperatures at time of the cart fill in the kitchen but not at time of distribution to residents. The DM stated she was only managing temperatures in the kitchen. During an interview on 10/1/24 at 3:31 p.m. with Resident 7, Resident 7 stated the food is not good and is cold all the time. Resident 7 stated the chicken and corn served at lunch today was cold. Resident 7 stated she has lost a few pounds because the food is not good. During an interview on 10/1/24 at 3:37 p.m. with the Administrator (ADM) and the DON, the ADM acknowledged that cold food has come up. Reviewed menus for 8/5/24 to 8/18/24, and additional menus provided with temperatures entered for 8/19/24 to 9/12/24. The ADM acknowledged that temperature monitoring was incomplete, and the prior cook was not documenting food temperatures. The ADM acknowledged 055446 Page 2 of 3 055446 10/01/2024 Rock Creek Care Center 260 Racetrack Street Auburn, CA 95603

F 0804 that a test tray temperature log was not found. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Policy and Procedure (P&P) titled Meal Service, dated 2023, .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures The Food and Nutrition Services staff member will take the food temperatures prior to service of the meal .The food will be served on trayline at the recommended temperatures .and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under the therapeutic diet column of each food served .The temperatures of the foods should be periodically monitored throughout meal service to ensure proper hot or cold holding temperature .Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot . Residents Affected - Some A review of the facility's P&P titled Covered Food During Transport, dated 2023, indicated .All hot food will be covered to maintain the proper temperature . 055446 Page 3 of 3