Inspection·January 24, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some months. DA B also revealed he was trained on dietary services and in-serviced by the DM every two weeks. DA B revealed the DAs were responsible for labeling and dating food and beverages stored in the refrigerators and dry food storage room daily. DA B explained any open food or beverages were labeled and dated. DA B revealed the DM was responsible for verifying that food and beverages stored in the refrigerators and dry food storage room were labeled and dated. DA B did not know how often the DM verified that food and beverages were labeled and dated. DA B also did not know who stored food and beverages in Refrigerator unit #1 and the dry food storage room without a label and date. DA B explained he was responsible for restocking and labeling the gallons of milk in Refrigerator unit #1. DA B did not know who was responsible for labeling and dating the gallons of milk in Refrigerator unit #1. DA B explained DA A labeled and dated food and beverages in Refrigerator unit #1 and the dry food storage room. DA B revealed residents were at risk of becoming sick if they consumed milk from a gallon that was opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 2:54 p.m., DA C revealed she worked at the facility for six months. DA C also revealed she was trained on dietary services and in-serviced by the DM every two weeks. DA C revealed all kitchen staff, which comprised of DAs, cooks and the DM, were responsible for labeling and dating food and beverages whenever the facility received new inventory and whenever food or a beverage was opened. DA C also revealed the DM was responsible for verifying that food and beverages were labeled and dated. During an interview on 01/24/24 at 3:04 p.m., DA D revealed she worked at the facility for one year. DA D also revealed she was trained on dietary services and in-serviced by the DM every two months. DA D revealed the DAs were responsible for labeling and dating food and beverages whenever they were opened. DA D also revealed the DM was responsible for verifying that food and beverages were labeled and dated. DA D revealed residents' health could be at risk if they consumed food and beverages that were opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 3:30 p.m., the DM revealed she worked at the facility for one year. The DM also revealed the DON, ADM, and ADON trained and in-serviced her dietary staff on dietary services. The DM revealed the DAs were responsible for storing, sealing, labeling, and dating food and beverages. The DM explained the cooks were responsible for labeling and dating the opened and left over food from meal service. The DM further explained she was responsible for verifying food and beverages were labeled and dated when she started her work shift, after breakfast, after lunch, and after dinner meal service. The DM explained she visually checked the dry food storage room, refrigerators and freezers to make sure food and beverages were labeled and dated. The DM revealed residents' health could be negatively impacted if they consumed food and beverages that were opened and not labeled with a shelf and open date. During an interview on 01/24/24 at 3:54 p.m., The DON revealed residents could become sick if they consumed food and beverages that were opened and not labeled with a shelf and open date. An attempt to interview [NAME] A was made on 01/24/24 at 4:21 p.m. by telephone. The surveyor left a voicemail and call back number. Record review of the Dietary Aide position description, undated, reflected the following job responsibilities: -Report missing/illegible labels to your supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 2 of 3 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 Record review of the [NAME] position description, undated, reflected the following job responsibilities: Level of Harm - Minimal harm or potential for actual harm -Report missing/illegible labels to the Director of Food Services. Residents Affected - Some Record review of the Dietary Department Director position description, undated, reflected the following job responsibilities: -Directs and manages all facility dietary functions and personnel -Assures that proper storage is available, and that handling of food and supplies complies with federal guidelines Record review of the Dietary Department's daily cleaning schedule, from 01/10/24 through 01/24/24, reflected DA A and the DM signed off on verifying that food was labeled and dated daily. Record review of the facility's in-services given to dietary staff from October 2023 through January 2024 reflected no documented evidence the staff were not trained on food storage and labeling. Record review of the facility's food receiving and storage policy and procedure, dated October 2022, reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). Such foods will be rotated using a 'first in - first out' system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 3 of 3