Health inspection·April 4, 2023

F 0637 Assess the resident when there is a significant change in condition 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 complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 4 residents (Residents #39) whose records were reviewed for assessments. Residents Affected - Few 1) The facility failed to recognize and assess Resident #39's weight loss, IV medications while in the facility, decline in ADL's and a decline in Bowel and Bladder function. This failure placed residents at risk for not being assessed for a change in condition and the need to revise their care plans to address changes in condition and develop interventions to meet their needs for care assistance and treatments. The findings included: Review of Resident #39's Face Sheet, dated 04/04/2023, reflected Resident #39 was a [AGE] year-old female re-admitted to the facility on [DATE]. The resident had Acute Respiratory Failure with Hypoxia (impaired gas exchange between the lungs and blood), Bacterial Infection (infection by microorganisms that invade the tissue), and malnutrition (lack of proper nutrition). Review of Resident #39's MDS assessments showed significant changes from her Quarterly MDS Assessment 10/09/2022 to her Quarterly MDS Assessment 11/29/2022 as follow: 1) The Quarterly MDS dated [DATE] section G revealed the resident had extensive assistance in dressing and was not steady but able to stabilize with staff assistance while moving from seated to standing position, was not steady but able to stabilize with staff assistance in walking, was not steady but able to stabilize with staff assistance in turning around, was not steady but able to stabilize with staff assistance in moving on and off toilet and was not steady but able to stabilize with staff assistance in surface to surface transfers. A wheelchair was used for mobility devices. The Quarterly MDS dated [DATE] section G revealed the resident had total dependance in dressing, activity did not occur in transfers, activity did not occur while moving from seated to standing position, activity did not occur in walking, activity did not occur in turning around, activity did not occur in moving on and off toilet and activity did not occur in surface-to-surface transfers. None of the above was used for mobility devices. 2) Resident had a significant weight loss from 10/09/2022 to 11/29/2022. The Quarterly MDS dated [DATE] section K revealed the resident weighed 195 with no significant weight loss or weigh gain coded. The Quarterly MDS dated [DATE] section K revealed the resident weighed 171 with no significant Page 1 of 16 455916 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0637 weight loss or weight gain coded. Level of Harm - Minimal harm or potential for actual harm 3) Review of the MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident was not receiving IV Medications while in the facility and was receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 0 days of Antibiotics, 7 days of Antidepressants and 7 days of Antianxiety. Residents Affected - Few The MDS Quarterly assessment dated [DATE] revealed in Section O in treatments that the resident received IV Medications while in the facility and was not receiving Oxygen Therapy while in the facility. Section N in medications revealed the resident received 7 days of Antibiotics, 0 days of Antidepressants and 0 days of Antianxiety. Observation and interview on 04/02/2023 at 10:30 AM revealed Resident #39 was alone in her room lying in her bed. She stated that she had been doing much better after her recent hospitalization. In an interview on 04/02/2023 at 3:15 PM, the MDS Coordinator said that Resident #39 had a significant change and that a significant change assessment should have been completed within 14 days after the change. She said failure to do a significant change assessment could result in inadequate care areas and an appropriate care plan not being established. She said she did not know that she needed to complete a Significant Change Assessment with some of these areas and she had not realized she had more than one care area where the resident declined. She stated she knew the resident had a weight loss and she forgot to code it. She said that she was the one responsible for completing and the assessment and ensuring it was done accurately. Review of the facility's policy and procedure for Resident Assessment, dated 2003, revealed the following [in part]: A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument in (RAI). The assessment will include at least the following: Medically defined conditions and prior medical history Medical status measurement Physical and mental functional status Nutritional status and requirements Special treatments or procedures Drug therapy RAI assessments must be conducted within 14 days after the date of admission, probably after a significant change in the residence physical or mental condition as soon as the resident stabilizes at a new functional are cognitive level or within two weeks, whichever is earlier The results of the assessment are used to develop, review, and revise the residence comprehensive 455916 Page 2 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0637 plan of care. Level of Harm - Minimal harm or potential for actual harm Any individual who willing play knowingly certifies or causes another individual to certify immaterial and false statement in a resident assessment will be terminated in a septic to civil many penalties. Residents Affected - Few 455916 Page 3 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure assessments with the pre-admission screening and resident review program (PASRR) were conducted for 1 of 3 residents (Resident #56) reviewed for PASRR evaluations. Residents Affected - Few The facility failed to complete a Level II PASRR Evaluation for Resident #56. This failure could affect the residents with a diagnosis of mental illness and could result in these residents not receiving needed services. The findings included: Resident #56's Face Sheet, dated 04/02/2023, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #56 had a diagnosis of bipolar disorder and generalized anxiety disorder. Review of Resident #56's PASRR Level 1 Screening, dated 07/21/2021, reflected a positive screening for mental illness. The resident's PE for mental illness was not completed as of 04/02/2023. In an Interview on 4/02/23 at 9:42 AM, the MDS Coordinator was asked if she knew that Resident #56's diagnosis of manic depression disorder should trigger a positive PASRR screening, she responded that it was, and she was working to correct the mistakes at this time. She did not realize the PE was not processed or completed. She stated there was a miscommunication and she did not follow through with why it was not completed. In addition to MDS coordination, her role was to monitor PASRR screenings. The MDS Coordinator stated that she was correcting the issue and was going to contact the LMHA and have them complete the PE. Review of the facility policy for PASRR Evaluation PE Policy and Procedures, dated 10/30/2017, revealed the following [in part]: Policy: It is the policy of Creative Solutions in Healthcare to ensure the LIDDA and/or LMHA complete a PE within the appropriate time periods (14 days). 455916 Page 4 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the state mental health authority promptly for resident review after a significant change in mental condition for two residents (Residents #21 and #55) with the PASRR screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not update the PASRR Level 1 forms for Resident #21 and Resident #55. This failure placed the residents at risk for not being evaluated for psychiatric conditions and not receiving needed PASRR specialized services for which they may be eligible. The findings included: Resident #21 Review of Resident #21's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of schizoaffective disorder (mental disorder with abnormal thought process) and generalized anxiety disorder (persistent anxiety). Resident #21's additional diagnoses were added on 08/25/2022 and included Post traumatic stress disorder (behavioral disorder that develops after exposure to trauma). Review of Resident #21's Physician Orders dated 04/28/2022 revealed orders for Risperdal 0.5mg for bipolar and schizoaffective disorder. Review of Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 could understand others and was usually understood by others; had a mild cognitive impairment with a BIMS score of 8 out of 15. Review of Resident #21's Care Plan dated 03/23/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems. Review of Resident #21's PASRR Level One Screening Forms dated 05/17/2021 revealed Resident #21 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after a diagnosis of post-traumatic stress disorder was added on 08/25/2022. An updated PL1 was completed and resubmitted on 04/02/2023. Resident #55 Review of Resident #55's Face Sheet dated 04/02/2023 revealed she was admitted to the facility on [DATE] with Admitting diagnosis of generalized anxiety disorder (persistent anxiety). Resident #55's additional diagnoses were added on 08/25/2022 included psychotic disorder with delusions (mental disorder with paranoid delusions). Review of Resident #55's Physician Orders dated 04/28/2022 revealed orders for Seroquel 25 mg two times a day for psychotic disorder with delusions. 455916 Page 5 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0646 Level of Harm - Minimal harm or potential for actual harm Review of Annual MDS dated [DATE] revealed Resident #55 could usually understand others and was usually understood by others and had mild cognitive impairment with a BIMS score of 8 out of 15. Review of Resident #55's Care Plan dated 02/22/2023 revealed complications associated with psychotropic medications and to monitor for target behaviors. Resident had behavioral problems and mood problems. Residents Affected - Some Review of Resident #55's PASRR Level One Screening Forms dated 07/10/2021 revealed Resident #55 had a diagnosis and was positive for mental illness. An updated PL1 was not completed after Seroquel was ordered for psychotic disorder with delusions. An updated PL1 was completed and resubmitted on 04/02/2023. In an interview on 04/02/2022 at 10:05 AM, the MDS Coordinator said that she thought she did not have to update a PL1 when the resident's condition changed. She stated she contacted her regional manager, and she informed her that it was to be updated if the resident's condition changed. Review of the facility's PASRR Policy and Procedures, dated 10/30/2017, revealed the following [in part]: Significant Change in status: If the resident's status has changed significantly enough from the initial reviewed status, they must have a new PASRR Level 1 to determine if they now are eligible for PASRR specialized services. 455916 Page 6 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #21) reviewed for Comprehensive Care Plans. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care. The findings included: Record review of Resident #21's face sheet revealed he was an [AGE] year-old female, admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Record review of Resident #21's Annual MDS, dated [DATE], revealed in Section I diagnoses included: Psychotic Disorder and Anxiety Disorder. Section N showed 7 days of antipsychotic medications given. Record review of Resident #21's care plan revealed it did not have the antipsychotic medication (Seroquel) addressed in the comprehensive care plan. Record review on 04/02/2023 of Resident 21's orders showed an order for a Seroquel 35mg given two times a day for psychotic disorder with delusions. In an interview on 4/02/2022 at 10:22 AM, the MDS Coordinator said that she should have care planned the Seroquel after it triggered on the MDS from Section V. She said that she was behind and was having a difficult time making sure all of the stuff was completed. She said that they were implementing a new process that should make sure everything is care planned accurately. She said this failure could place the resident at risk for staff not recognizing adverse medication effects and behaviors. She was going to talk to the DON and make sure it was added. In an interview on 04/02/2023 at 1:30 PM, the DON said that it was the responsibility of the MDS Coordinator since an annual assessment was done and should have captured it. She stated that she would add it immediately and would start double checking to make sure there is no other areas missed. She stated that the resident was receiving the medication and they were observing her for adverse reactions or behaviors even though it was not care planned. A facility policy and procedure for comprehensive care plans was not received at the time of exit. 455916 Page 7 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 residents (Residents #219) reviewed for oxygen in that: Residents Affected - Few Resident #219 did not have physician's orders for oxygen administration. This deficient practice could affect 8 residents who received respiratory treatments and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings included: Record review of Resident #219's face sheet dated 04/04/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep and characterized by loud snoring and episodes of stop breathing). Record review of Resident #219's MDS Assessment for Medicare Part A Stay dated 03/30/2023, revealed a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and sleep apnea. The MDS assessment indicated Resident #219 received oxygen therapy. In an observation and interview on 04/02/23 at 9:33 AM, there was an oxygen concentrator in Resident's 219's room. A nasal cannula was connected to the concentrator and was bagged. There was a CPAP machine on her dresser next to her bed. She said that she used oxygen with her CPAP machine at night. She said she had sleep apnea and had been using this since she was admitted to the facility since last week. Record review of Resident #219's Physician Order Summary Report, dated 04/04/2023, revealed that there were no orders for oxygen administration. Record review of Resident #219's Care Plan revised on 04/03/2023, revealed: Focus - The Resident has COPD; Intervention - Give oxygen therapy as ordered by the physician. In an interview on 04/04/23 at 1:56 PM, the DON said Resident #219 should have had an order for oxygen administration with her CPAP machine. She said the admitting nurse should have put in the order. Failure to do so would risk the resident of not getting the oxygen support that was needed. Record review of the facility policy for Oxygen Administration, dated as revised February 13, 2007, revealed the following [in part]: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems . Goals: 1. The resident will maintain oxygenation with safe and effective delivery of prescribed 455916 Page 8 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0695 oxygen. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 455916 Page 9 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors, in that: Residents Affected - Many 1. The facility failed to update and post the daily nurse staffing information on 4/02/23. 2. The nursing staff on duty on 4/02/2023 did not know the current resident census. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. The findings included: Observation on 04/02/2023 at 09:05 AM revealed the daily nurse staffing pattern was not posted on the wall in the location designated for it. In an interview on 04/02/2023 at 9:15 AM, RN A could not explain why the daily nurse staffing information was not posted where it could be seen but RN A did show where it was located in a three-ring binder at the nurses' station. The facility had a standardized form for documenting the date, resident census, and nurse staffing hours for each shift. In an interview on 04/02/2023 at 9:20 AM, RN A stated she worked weekends, double shifts, from 6:00 AM to 10:00 PM. She stated she did not know the current resident census. In an interview on 04/04/2023 at 02:00 PM, the DON said she did not understand why the daily nurse staffing information was not put out. The DON said that she placed the daily nurse staffing form for Friday, Saturday, and Sunday in the binder before she leaves the facility for the staff to put out (post). 455916 Page 10 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: Residents Affected - Many 1. The dietary staff did not operate the low temperature dish machine and check the chlorine sanitizer content to ensure it was operating correctly to clean and sanitize the dishes consistently each meal. 2. Dietary Aide C did not use disposable gloves while handling soiled dishes and did not wash or sanitize his hands before handling the clean dishes. 3. Food items in the non-perishable food storage areas were not stored in sealed containers or resealable storage bags after the manufacturer's package seal was opened. 4. Floors were soiled throughout the kitchen food preparation area. 5. The deep fryer unit was soiled with dried fried food crumbs and contained dark colored cooking oil. 6. The reach-in freezer unit #2 interior temperature was not maintained at zero degrees F or lower and foods stored in the unit were not frozen solid. The facility's failure placed residents at risk for foodborne illness and a decline in health status. The findings included: Observation on 4/02/23 at 9:25 AM, during the initial tour of the facility kitchen revealed the hand washing sink was located by the door to the short hallway that led to the nurses' station. There was not another hand washing sink in the kitchen or dish washing room. Interview and observation on 4/02/23 at 9:30 AM revealed Dietary Aide C was washing dishes in the low temperature dish machine. He was not wearing gloves when handling the soiled dishes. He stated he had worked in facility for about 1 month. Review of the dish machine temperature log form, dated April 2023, revealed columns to document wash and rinse water temperatures and sanitizer levels 3 times daily. No entries were documented on the form for 4/01/23 or breakfast 4/02/23. Observation on 4/02/23 at 9:35 AM revealed Dietary Aide C operated the dish machine. He started to record temperatures for breakfast on 4/01/23, then scratched them out when reminded today was 4/02/23. When Dietary Aide C checked the chlorine sanitizer content, the test strip did not react when dipped in the dish machine water. He primed the sanitizer and ran the dish machine again. No sanitizer was observed in the tube that emptied into the dish machine. Dietary Aide C checked the one-gallon sanitizer bottle, which was almost full. He removed the bottle cap which was connected to tubing and observed the siphon device was stuck down in the neck of the bottle and did not reach the cap. He 455916 Page 11 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0812 stated he would go to the storage room and get another bottle of sanitizer. Level of Harm - Minimal harm or potential for actual harm In an interview and observation on 4/02/23 at 9:40 AM, after returning to the kitchen, Dietary Aide C stated he could not find another bottle of sanitizer. He stated he was not going to wash dishes by hand and stated he might as well go home. He removed the cap to the sanitizer bottle and was able to pry the siphon device to the top of the bottle neck with a knife. He replaced the bottle cap with the tubing, primed the dish machine again and ran the machine. Chlorine sanitizer was observed flowing through the tubing and emptying into the dish machine. He tested the sanitizer and measured a level of 200 ppm. Observation of the low temperature dish machine manufacturer's recommendations revealed wash and rinse water temperatures at a minimum of 120 degrees F and a sanitizer level minimum of 50 ppm. When asked about the procedure for handling soiled and clean dishes, Dietary Aide C stated he put the dirty dishes in the racks, ran them through the dish machine, and then stacked the clean dishes. Inquired if he washed or sanitized his hands between touching the soiled and clean dishes, as he was not using disposable gloves, and he stated no. A two-compartment sink for rinsing dishes was in the dish room, but there was no hand soap, paper towel dispenser, or hand sanitizer in the room. Dietary Aide C stated he would start using gloves when handling dirty dishes. He got gloves from a box in the kitchen and put them on his hands. Residents Affected - Many Observation and interview on 4/02/23 at 10:00 AM, during the initial tour of the facility kitchen revealed the following: - The reach-in refrigerator unit contained a rectangular pan covered with foil which was not labeled or dated. [NAME] D removed the pan from refrigerator and placed the pan on the stove top. She lifted the foil and stated it looked like a roast. The piece of meat had been cooked as a whole piece of meat (not sliced) and was surrounded by white colored cold grease/fat. [NAME] D stated she did not know when it had been cooked. - The reach-in freezer unit #2 had an interior thermometer with a temperature of 25 degrees F. The freezer was filled with unevenly stacked cardboard boxes, dated 3/29/23, which contained sweet dough and beef steak fritters (meat patties) which were not frozen solid. - The exterior surfaces of the stainless steel reach-in refrigerator and freezer units were soiled with dried food splatters. - The storage room for storing bread items on shelf rack had an open bag with potato chips rolled closed and dated 3/28/23. The potato chips were not in a sealed container or resealable bag. - The non-perishable food storage room had wire rack shelf units for storing dry food items. A large plastic bag containing flake coconut, dated 3/23/22, was rolled closed and had a trombone paper clip; a 5-pound bag with pecan pieces, dated 3/08/23, was rolled closed and had a trombone paper clip. The coconut and pecans were not in sealed containers or resealable bags. - The deep fryer unit top surface was covered with a large rectangular baking sheet and was not in use. The pan was moved to the side and dark colored cooking oil and fried food crumbs on the interior surface were observed. - The floor was soiled with food throughout the kitchen. In an interview on 4/02/23 at 10:10 AM, [NAME] D stated the food on the floor was from breakfast 455916 Page 12 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many that morning and she had not yet swept the floor. She stated she sweeps the floor two times during her shift. In an observation and interview on 4/02/23 at 3:04 PM, a chest freezer was located in a storage room located in the short hallway outside the kitchen. A thermometer was not observed inside the freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. The DSM stated the roast in the reach-in refrigerator this morning was from last Wednesday, 3/29/23. She stated it should have been labeled and dated. When asked about the supply of chlorine sanitizer for the low temperature dish machine, she stated she had more in storage. She stated the new bottle of sanitizer must have been defective. In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake. In an interview on 4/04/23 at 11:35 AM, the DSM stated she had worked as a dietary aide and dishwasher for the morning shift on Saturday, 4/01/23. When asked if she had changed the bottle of chlorine sanitizer for the dish machine that day, she stated no and she did not recall doing it. The DSM stated the evening shift dietary aide would have switched the sanitizer bottle with a new one. She did not recall checking the wash and rinse water temperatures and chlorine sanitizer for the Saturday 4/01/23 breakfast and lunch meals. When asked about the April 2023 dish machine temperature and sanitizer log not having any documented entries for 4/01/23, she stated she had not checked them. Review of the facility's policy and procedure for Dishwashing Preparation and Dishwashing, included in the Dietary Services Policy and Procedure Manual 2012 , revealed the following [in part]: The facility will complete the dishwashing process in a sanitary manner to provide clean and sanitary dishes and utensils. Procedure: 2. Automatic dishwasher: Low temperature machine . d. Prior to washing the soiled dishes after a meal, the dish machine should be tested for proper temperature and PPM of sanitizing solution. The dish machine may need to be run empty for a few cycles to ensure the proper temperature is attained, and no dishes will be washed prior to achieving this standard. e. Hands should be sanitized before touching clean items and use care in removing utensils from conveyors in order not to contaminate clean items . Review of the facility's policy and procedure for Food Storage and Supplies, included in Dietary Services Policy and Procedure Manual 2012, revealed the following [in part]: All facility storage areas will be maintained in and orderly manner that preserves the condition of food and supplies. Will ensure storage areas are clean, organized, dry and protected from vermin 455916 Page 13 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0812 and insects. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Many 4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened. 5. Storeroom floors should be swept and mopped to be maintained in a sanitary manner to prevent vermin or pest infestation . Review of the U.S. Food and Drug Administration, 2017 Food Code, specified [in part]: Food storage/labelling 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. 6-501.12 Cleaning, Frequency and Restrictions. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. 455916 Page 14 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that: Residents Affected - Many One of two reach-in freezers was not maintained at an interior temperature of zero degrees or below and food stored in the freezer was not frozen solid. This failure placed the residents at risk for foodborne illness from being served food that had not been stored at the proper temperature. The findings included: Observation on 4/02/23 at 10:00 AM revealed a row with one reach-in refrigerator unit and two reach-in freezer units. Observation of reach-in freezer unit #1 revealed an interior thermometer with a temperature of -4 degrees F. Freezer unit #1 contained vegetables in clear plastic bags and the vegetables were frozen solid. Observation of reach-in freezer unit #2 revealed an interior thermometer with a temperature of +25 degrees F. Freezer unit #2 contained cardboard boxes dated 3/29/23. The boxes were unevenly stacked to the ceiling of the freezer. A box contained sweet dough, which was thawed and soft, and a box contained beef steak fritters (meat patties) which were not frozen solid. In an interview on 4/02/23 at 10:02 AM, [NAME] D stated grocery delivery was received one time weekly on Wednesdays. She stated the grocery boxes dated 3/29/23 were from the delivery last week. The [NAME] left the kitchen through the door to the short hallway that led to the nurses' station. In an interview on 4/02/23 at 10:05 AM, [NAME] D stated she had called the DSM and she had not answered. She stated the DSM was good about calling back. [NAME] stated D stated she had talked with the nurses about the reach-in freezer unit, and they would try to reach the maintenance man. In an interview on 4/02/23 at 2:43 PM, the Administrator stated the Maintenance Director was trying to repair the reach-in freezer. In an interview on 4/02/23 at 2:48 PM, the DSM stated there had not been a problem with the end reach-in freezer unit #2 and it must have started during the past few days. She stated she would take all the food from the end freezer unit #2 and place it in the middle freezer unit #1 and in the chest freezer in the hallway storage room. The DSM stated she would defrost freezer unit #2. She stated if the freezer unit did not work after that it would need to be serviced. She stated the freezer was not older than 2 years. In an interview on 4/02/23 at 2:52 PM, the Maintenance Director stated the boxes of food in the reach-in freezer #2 were stacked too close together and too high and were blocking the fan. He stated the food needed to be removed and the freezer needed to be defrosted and then it should work ok. Observation and interview on 4/02/23 at 3:04 PM revealed a chest freezer was in the storage room located in the short hallway leading from the kitchen. The chest freezer had space for additional food from freezer unit #2 in the kitchen. A thermometer was not found inside freezer, but the food was frozen solid. The DSM stated she would place a thermometer in the chest freezer. A thermometer was observed on the wire rack shelf unit located to the left of the freezer. The DSM stated it probably belonged in the chest freezer. 455916 Page 15 of 16 455916 04/04/2023 University Park Nursing and Rehabilitation 4511 Coronado Ave Wichita Falls, TX 76310

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 4/03/23 at 9:43 AM revealed all food items had been removed from the reach-in freezer unit #2 and the unit had been defrosted. The fan blades in the interior ceiling had not yet been covered. Observation on 04/03/2023 at 9:43 AM of the reach-in freezer unit #1 revealed it contained food items, including the beef steak fritters, that had been removed from freezer unit #2. Observation and interview on 4/04/23 at 8:35 AM revealed reach-in freezer unit #2 was running and the interior thermometer temperature was 12 degrees F. The freezer remained empty at that time. The Maintenance Director stated he needed to replace the cover for the fan in the ceiling of the unit. In and interview and observation on 4/04/23 at 11:10 AM, the DSM stated she had gone to the store and had bought dinner rolls for the lunch meal today, due to throwing away the sweet dough that had not been frozen solid in freezer unit #2 on 4/02/23. She gave the frozen dinner rolls to an unidentified dietary staff member, who proceeded to place the frozen dinner roll dough on baking sheets and put them in the oven to bake. In an interview on 4/04/23 at 1:55 PM, the DSM stated she had 3 freezers, the 2 reach-in freezers in the kitchen and the chest freezer in the supply room. She stated freezer unit #2 was only about 2 years old. She stated she never had problems with reach-in freezer #1, and it was the oldest unit. She stated daily freezer temperatures were documented on the temperature log form. She stated she would look for a policy and procedure for maintenance of equipment and temperatures. Review of the daily freezer temperature log forms revealed columns for documenting temperatures 2 times daily, in the morning and in the evening. Review of the March 2023 daily temperature log for Freezer #1 revealed a temperature of -10 degrees F was consistently documented daily in the morning and the evening. Review of the March 2023 daily temperature log for freezer unit #2 revealed the documented morning and evening temperatures were above zero and ranged from 6 degrees F to 24 degrees F, except on 3/28/23 which documented -10 degrees F for both the morning and evening (possibly a documentation error). The documented morning temperature on 3/29/23 was 10 degrees, on 3/30/23 was 8 degrees, and on 3/31/23 was 11 degrees. No temperatures were documented for the evening on 3/29/23, 3/30/23, and 3/31/23. A policy and procedure for maintaining essential kitchen equipment, including checking and documenting refrigerator and freezer temperatures, was not provided as requested prior to exit. 455916 Page 16 of 16