Health inspection·April 8, 2025

F 0812 During observation in the kitchen refrigerator on 4/7/25 at 9:45 am the following was observed with the Dietary Manager: Level of Harm - Minimal harm or potential for actual harm - Residents Affected - Some (1) cut up tomato prepped on 4/6/25 had no expiration date. (1) 6-ounce container of pineapples with a prep date of 4/1/25 had no expiration date. (1) Quart of white gravy had an expiration date of 4/7/25 and no preparation date. (expired) (11) cups of orange juice had a preparation date of 4/7/25 and no expiration date (40) cups of teas were not labeled, had no preparation date and no expiration date (20) cup of water was not labeled, had no preparation date and no expiration date (1) plate of salad had a preparation date of 4/6/25 and no expiration date During observation in the kitchen freezer on 4/7/25 at 9:52 a.m., the following was observed with the Dietary Manager: (1) zip lock bag of French fries had an open date of 4/5/25 and no expiration date (1) zip lock bag of French fries had an open date of 4/6/25 and no expiration date (1) bag of frozen diced chicken had an expiration date of 4/4/25 an no open date. (expired) During an interview with the Dietary Manager on 4/7/25 at 9:37 a.m., The Dietary Manager stated staff were cleaning the fryer but had not been signing off that they had been cleaning the fryer. The Dietary Manager stated the fryer was to be cleaned once a week. The Dietary Manager stated she worked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 2 of 4 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Monday thru Friday and sometimes on the weekend. The Dietary Manager stated she ensured staff were cleaning because she watched what her staff did and how her staff cleaned. The Dietary Manager stated the fryer was used every day. The Dietary Manager stated the fryer was last cleaned on Monday 3/31/25. The Dietary Manager stated staff were to put their initials on the daily cleaning schedule indicating what was cleaned and by whom it was cleaned by. The Dietary Manager stated she did not know why staff did not initial on 3/31/25 indicating the fryer had been cleaned but it was okay because it was going to fall on her indicating that she should have checked to make sure staff initialed the cleaning schedule for each day. The Dietary Manager stated the foods prepared in the kitchen should be labeled, have a preparation date and an expiration date. The Dietary Manager stated once food was prepared that it was good for 7 days. The Dietary Manager stated in-services on labeling and dating had been completed a few months ago. The Dietary Manager stated it was important to ensure staff were labeling and dating food items and cleaning the fryer to keep the residents from getting sick, to prevent sending out spoiled food to the residents and to prevent the residents from getting salmonella. The Dietary Manager stated the Administrator oversaw her at the facility. The Dietary Manger stated she was responsible for ensuring staff were labeling and dating food items and responsible for ensuring staff were cleaning the fryer weekly. During an interview on 4/7/25 at 11:12 a.m., Confidential Complainant stated the kitchen was filthy. Confidential Complainant stated the grease was changed once a month in the kitchen. Confidential Complainant stated the fryer was used every day. During a phone interview on 4/8/25 at 9:23 a.m., the Administrator stated she had been employed since June 3 of 2024. The Administrator stated she over saw the Dietary Manager. The Administrator stated she tried to do walk thru biweekly. The Administrator stated her last walk thru was on 4/3/25 (Thursday). The Administrator stated all food items in the refrigerator were to be labeled, dated with receive date, open date and expiration date. The Administrator stated recently staff had completed in-services on labeling and dating all food items. The Administrator stated staff had not completed in-services on cleaning the deep fryer recently. The Administrator stated she was not aware of the expired food items not being discarded and the deep fryer was not getting cleaned weekly. The Administrator stated she did expect the Dietary Manager to report to her all issues found in the kitchen. The Administrator stated it was important to ensure staff was labeling, dating and resealing refrigerator and frozen food items and cleaning the fryer weekly to ensure cleanliness, to provide the highest quality of food and to ensure safety for the residents. Record Review of the kitchen policy titled, Equipment cleaning Procedures dated on 12/13/17 indicated, Cleaning Frequency: (daily) Equipment and items that are used in food preparation should be cleaned and sanitized after each use. Kitchen and storeroom floors should be swept and mopped daily. (Weekly) If the fryer is used frequently (five or more times a week), clean weekly. If fryer is used less often than that, clean monthly. If grease is strained after each use, it extends the life of the grease. Record review of the kitchen policy titled Frozen and Refrigerated Foods Storage with review dated on 11/15/17, indicated, (7) Refrigerate cooked foods in shallow containers to speed the cooling process. Proper labeling of cooked foods includes the date placed in the refrigerator, and an expiration or use by'' date. Refrigerated products that are opened must be labeled with an opened on date. The ''use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. For all foods that have a manufacturer use by, sell by or expirations dates this date will be used. Examples of foods that typically have manufacturer, use by, sell by or expirations dates are cottage cheese, milk, sour cream, pre-pared refrigerated salads etc. Foods (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 3 of 4 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 455579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sulphur Springs Health and Rehabilitation 411 Airport Rd Sulphur Springs, TX 75482 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 Level of Harm - Minimal harm or potential for actual harm prepared in the building and properly cooled will be dated as to the date prepared and ''use by'' date which will be 7 days from the date prepared; (11) All refrigerated and frozen items in storage will contain a minimum label of common name of product and dated as noted above. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455579 If continuation sheet Page 4 of 4