Health inspection·June 16, 2025

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Serve residents food timely and at a palatable (pleasant to taste) temperature for two of three sampled residents (Resident 1, Resident 2). 2. Document food temperatures prior to distributing the residents meals for two of three sampled residents (Resident 1, Resident 2). These failures had the potential for reduced resident meal intake and the potential for the residents to contract food borne illness. Findings: 1. During a review of Resident 1's Minimum Data Set (MDS -a standardized assessment to evaluate a resident ' s functional abilities and healthcare needs), dated 1/30/25, under the section Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns], the BIMS score was 15 (cognition intact). During an interview on 6/16/25 at 12:30 p.m. with Resident 1, Resident 1 stated at times (not specific) his meals come in very late, and the food can be cold when it is delivered. Resident 1 stated he loves to have coffee and when it is brought to him the coffee can be cold. Resident 1 stated he had not received his lunch meal yet. During a review of Resident 2's MDS dated [DATE], under the section BIMS, the BIMS score was 12. During an interview on 6/16/25 at 12:49 p.m. with Resident 2, Resident 2 stated meals were being served late. Resident 2 stated it is now 1:12 p.m. and lunch has not been provided. Resident 2 stated yesterday (6/15/25) she did not receive her dinner until 9 p.m. Resident 2 stated the food that is supposed to be hot is cold, and the food that is supposed to be cold is warm or hot. Resident 2 stated for example, when she is served milk it is warm. During an interview on 6/16/25 at 1:37 p.m. with Dietary Supervisor Assistant (DSA), DSA stated she has been aware of resident complaints (not specific who) regarding meals being served late. DSA stated the last complaints she heard about late meals were over the weekend. DSA stated breakfast should start to be served at 6:30 a.m. and all residents should have their meals by 7:30 a.m., Lunch should start to be served at 11:30 a.m. and all residents should be served by 12:45 p.m., Dinner should start to be served at 4:30 p.m. and all residents should be served by 5:45 p.m. Page 1 of 4 555256 555256 06/16/2025 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent observation and interview on 6/16/25 at 1:59 9.m. with DSA, the last lunch meal tray was served, and food temperatures were taken. DSA observed and confirmed the following food temperatures: a. Sweet potato fries were 101.5 degrees Fahrenheit (°F). DSA stated the temperature should have been 145 °F. b. Roast beef sandwich was 100 °F. DSA stated the temperature should have been 165 °F. c. Chocolate pudding was 66.6 °F. DSA stated the temperature should have been 41 °F or lower. d. Coleslaw was 70.9 °F. DSA stated the temperature should have been 41 °F or lower. e. Milk was 64.6 °F. DSA stated the temperature should have been 41 °F or lower. f. Chocolate milk was 60 °F. DSA stated the temperature should have been 41 °F or lower. g. Coffee was 159°F. DSA stated she was not sure what the temperature of coffee for residents should be. DSA stated the temperatures of food and drinks should be per the policy and procedure to prevent residents from getting sick. 2. During a concurrent interview and record review on 6/16/25 at 1:24 p.m. with DSA, the facility Food Temperature Log (FTL), dated June 2025 was reviewed. The FTL indicated the following missing temperature entries missing: a. On 6/1/25 - There were no temperature entries for facility residents dinner dessert, milk, juice, starch substitute (range of plant foods including grains like wheat, rice, barley, oats, rye, corn, and breads and potatoes) and meat substitute. b. On 6/2/25 - There was no temperature entry for facility resident lunch meat substitute. c. On 6/3/25 - There were no entries for facility resident lunch and dinner meat and starch substitute. d. On 6/4/25 - There were no entries for facility resident dinner meat and starch substitutes. e. On 6/5/25 - There were no entries for facility resident lunch meat substitute. There were no entries for facility resident dinner meat and starch substitutes. f. On 6/6/25 - There were no entries for facility resident dinner meat and starch substitutes. g. On 6/7/25 - There were no entries for facility resident dinner meat and starch substitutes. h. On 6/8/25 - There were no entries for facility resident lunch and dinner meat and starch substitutes. 555256 Page 2 of 4 555256 06/16/2025 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0804 i. On 6/9/25 - There were no entries for facility resident lunch and dinner meat and starch substitutes. Level of Harm - Minimal harm or potential for actual harm j. On 6/10/25 - There were no entries for facility resident dinner meat and starch substitutes. k. On 6/11/25 - There were no entries for facility resident dinner milk, meat, and starch substitutes. Residents Affected - Some l. On 6/12/25 - There were no entries for facility resident dinner meat and starch substitutes. m. On 6/13/25 - There were no entries for facility resident dinner soup, entrée (main portion of the meal), mechanical soft (a type of diet texture) entrée, gravy, vegetable, starch, puree (a type of diet texture) meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. n. On 6/14/25 - There were no entries for the facility residents breakfast juice, and milk. No entries for the facility resident lunch milk, juice, meat substitute, and starch substitute. No entries for facility resident dinner soup, entrée, mechanical soft entrée, gravy, vegetable, starch, puree meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. o. On 6/15/24 - There were no entries for the facility resident dinner milk, juice, meat substitute, and starch substitute. p. On 6/16/25 - No entries for the facility resident lunch milk, juice, meat substitute, and starch substitute. No entries for facility resident dinner soup, entrée, mechanical soft entrée, gravy, vegetable, starch, puree meat, puree vegetable, puree starch, dessert, milk, juice, meat substitute, and starch substitute. DSA stated the temperature entries should have been placed into the log prior to the residents meal being served. DSA stated the FTL should be reviewed daily to ensure staff were placing the temperatures of the meals provided to residents. During a review of the facility ' s policy and procedure (P&P) titled, Food Temperatures, dated 9/28/23, the P&P indicated, Where to Record Temperature . Record the reading on DS16 -Form A - Temperature Log at the beginning of tray line making sure to take the temperature of each pan of product before serving. Acceptable Serving Temperatures . Cereal, gravy . > (greater than) 140 (degrees Fahrenheit) . Casseroles . >140 (degrees Fahrenheit) . Meat, entrees . >140 (degrees Fahrenheit) . Potatoes, pasta . >140 (degrees Fahrenheit) . Soup . >140 (degrees Fahrenheit) . Pureed food . >140 (degrees Fahrenheit) . Vegetable . >140 (degrees Fahrenheit) . Coffee . >140 (degrees Fahrenheit) . Hazardous salads, dessert . < (less than) 41 (degrees Fahrenheit) . Pastries, cakes . < 60 (degrees Fahrenheit) . Milk, Juice . <41 (degrees Fahrenheit) . Eggs . >140 (degrees Fahrenheit). If the temperature does not meet applicable serving temperatures, reheat the product or chill the product to the proper temperature . During a review of the facility ' s policy and procedure (P&P) titled, Meal Service Times, dated 7/1/14, the P&P indicated, Purpose . To provide the dietary department with guidelines for meal service. Meals are served at regularly scheduled hours . There is no more than 14 hours between dinner and breakfast the following morning . The Dietary Manager is responsible for monitoring meal service 555256 Page 3 of 4 555256 06/16/2025 The Rehabilitation Center of Bakersfield 2211 Mount Vernon Avenue Bakersfield, CA 93306

F 0804 time daily to ensure the facility meets posted meal times. Meal times are typically at 7:00am (a.m.), 12pm (p.m.), 5:00pm. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555256 Page 4 of 4