Health inspection·September 23, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review, the facility failed to follow the menu for 18 of 18 residents who received pureed diets (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) during the lunch meal service on 9/23/24, when the vegetable served did not reflect what was listed on the menu. This failure had the potential for residents ' preferences not to be met and could result in decreased meal intake. Findings: During an observation on 9/23/24 at 11:36 AM in the kitchen, [NAME] 1 placed cooked carrots into the blender, poured thickener and hot water into the blender, and pureed the items together. [NAME] 1 poured the pureed carrots into a serving dish and placed it on the steam table. During an interview on 9/23/24 at 1:45 PM with [NAME] 1 in the kitchen, [NAME] 1 confirmed she pureed carrots instead of the squash listed on the menu. [NAME] 1 stated all the residents who were on a pureed diet received pureed carrots instead of squash for the lunch meal. [NAME] 1 stated they didn ' t puree the squash because she was just busy doing other prep items. [NAME] 1 stated residents should have received the squash because it was on the menu for the day. During an interview on 9/23/24 at 2:23PM with the Administrator (Admin), the Admin stated menus were important for resident preferences and to accommodate their needs. The Admin stated if the menu was not known or not followed, needs of residents would not be met. The Admin stated Residents should be served items shown on the menu. The Admin confirmed expectations were not met. During a review of a facility document .SPRING MENU . dated 4/11/24 . indicated, .Monday .Apr-28, Jun-02, Jul-07, Aug-11, Sep-15 .Lunch .Aunties Baked Squash . A review of a facility policy and procedure (P & P) titled Menus, dated 2/2017 indicated, To ensure food/fluid variety, adequate nutrition, and allow for effective planning of food and dining service .All menus are dated and the current menu is posted in the facility so that it is available to the residents and staff . Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555470 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555470 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Creek Post-Acute 9289 Branstetter Place Stockton, CA 95209 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)