Health inspection·February 26, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate assessments were completed for 2 of 30 residents (Residents #6 and #87) reviewed for accuracy of assessments. Residents Affected - Few The facility failed to ensure Residents #6 and #87's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #6's face sheet for February 2025 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included schizoaffective bipolar disorder (mental health condition including schizophrenia and mood disorder), anxiety, and major depressive disorder. A review of Resident #6's PASRR Level 1 screening done 01/08/2021 indicated she was positive for mental illness. A review of Resident #6's PASRR Evaluation done 02/08/2021 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #6's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, schizophrenia, and schizoaffective bipolar disorder. Section N Medications indicated the resident received antipsychotic and antianxiety medications. 2. A review of Resident #87's face sheet for February 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #87's PASRR Level 1 screening done 02/26/2022 indicated he was positive for MI. A review of Resident #87's PASRR Evaluation done 04/14/2022 indicated he was positive for MI. The Page 1 of 6 455983 455983 02/26/2025 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #87's significant change MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety, depression, and bipolar disorder. During an interview on 02/26/2025 at 9:15 AM, MDS Coordinator B said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said if she had any questions regarding the MDS assessment she went directly to the RAI manual. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said she had been taught if the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and she was told to answer no because they were negative. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. 455983 Page 2 of 6 455983 02/26/2025 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (second floor, third floor, fourth floor). The facility failed to ensure the cornmeal, sugar, breadcrumbs, salt, and parboiled rice packages were re-sealed in the dry pantry. The facility failed to ensure the walk-in cooler for produce in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the walk-in freezer in the main kitchen did not have food packages stored on the floor. The facility failed to ensure the single door reach in cooler in the main kitchen was clean and free of food debris. The facility failed to ensure the small microwave in the main kitchen was clean. The facility failed to ensure the satellite kitchens were clean and free of dust. The facility failed to ensure DA A in the fourth floor satellite kitchen wore a hairnet over his beard. The facility failed to ensure DS C wore a hairnet in the main kitchen. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: 1.During observations and interviews on 02/24/25 of the main kitchen the following was noted: *at 10:25 AM in the Dry Pantry: 1-25 lb. [NAME] bag of Japanese panko breadcrumbs opened and not re-sealed. 1-50 lb. [NAME] bag of granulated sugar opened and not re-sealed. 1-25 lb. [NAME] bag of yellow cornmeal opened and not re-sealed. 1-25 lb. [NAME] bag of granulated plain salt opened and not re-sealed. 1-25 lb. box containing an opened bag of parboiled rice that was not re-sealed and also contained a plastic scoop inside the product. *at 10:30 AM in the walk-in cooler containing produce there were boxes stored on the floor that 455983 Page 3 of 6 455983 02/26/2025 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 contained fresh carrots, fresh cucumbers, oranges, and lettuce. Level of Harm - Minimal harm or potential for actual harm *at 10:41 AM in the walk-in freezer had these items stored on the floor: 2-three-gallon ice cream containers, Residents Affected - Some 1 case (12- 16 oz packages) of whipped topping, 1 case biscuit dough, and 2 cases of chocolate ice cream cups. *at 10:45 AM in the single door cooler containing pickles, salad, and mayonnaise had food debris on the bottom of the cooler. *at 10:46 AM the small microwave had dried food splatters. During an interview on 02/24/2025 at 10:10 AM, the acting DM said plates, cups, bowls, glasses, and silverware were all done in a dish machine on each floor of the SNF. She said there were 2 dietary servers on each floor that came and got the food items from the main kitchen and took it the floor and placed the food pans on the steam tables and served. She said the dietary servers did the dish washing. During an interview on 02/24/2025 at 11:05 AM, the acting DM said another employee was responsible for the pantry, coolers and freezer. She said he was off today but had been on duty on Sunday. She said he was responsible for putting away, stacking and labeling all food items, mopping and sweeping the floors. The DM said he should not have opened the breadcrumbs because her storage bin was full. She took the opened bags of cornmeal and sugar out of the pantry and placed them in the main kitchen area. She said she would empty them into her bulk bins. She did not do anything with the salt bag or parboiled rice package. Review of a facility policy, revised 01/2024, on Food and Supply Storage indicated All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption.store foods in their original packages. Foods that must be opened must be stored in approved containers that have tight-fitting lids.Store food items 6 inches above the floor, 2 inches from the walls, and 18 inches from the ceiling . Food and Drug Administration Code, Dated, 2013, indicated the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. .3-305.11 Food Storage 455983 Page 4 of 6 455983 02/26/2025 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 Food shall be protected from contamination by storing the food: Level of Harm - Minimal harm or potential for actual harm (1) In a clean, dry location; (2) Where it is not exposed to slash, dust or other contamination . Residents Affected - Some 2. During observations on 02/24/2025 the following was noted: *11:55 AM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:34 PM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:43 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During observations on 02/25/25 the following was noted: *11:50 AM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *11:54 AM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:00 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During observations on 02/26/25 the following was noted: *12:14 PM- The Satellite Kitchen on the 2nd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:21 PM- The Satellite Kitchen on the 3rd floor had an air vent directly above the serving steam table. There was dust on the air vent grates. *12:30 PM- The Satellite Kitchen on the 4th floor had an air vent directly above the serving steam table. There was dust on the air vent grates. During an interview on 02/26/2025 at 2:05 PM, the Maintenance Director said his department was responsible for cleaning the air vents in the satellite kitchens located on the 2nd, 3rd and 4th floors. The Maintenance Director said he was not aware the air vents had dust on them and needed to be cleaned until yesterday when the LSC surveyor pointed it out to him. The Maintenance Director said he did not know when the satellite kitchen vents were last cleaned, and it was an oversight on his part they were not. The Maintenance Director said the vents should be cleaned monthly to prevent dust from falling into the food and contaminating it. Record review of the facility's Sanitation and Infection Prevention/Control policy revised 01/2021 indicated, Policies: .The facility/community's Maintenance Department is scheduled to clean 455983 Page 5 of 6 455983 02/26/2025 St. Catherine Center 300 West Highway 6 Waco, TX 76712

F 0812 equipment that requires special training and equipment, such as the ice maker, refrigeration coils and exhaust hood .Procedures: .Assigns daily cleaning responsibilities in each position workflow . Level of Harm - Minimal harm or potential for actual harm The Texas Food Establishment Rules, dated October 2015, revealed: Residents Affected - Some §228.114. Frequency of Cleaning. .(c) Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues 3. During an observation in the fourth-floor satellite kitchen on 02/24/2025 at 1:06 PM, DA A was observed handling foods and making special food orders that were given to residents in the dining hall. DA A was not wearing a hairnet covering his beard. DA A said he was not wearing a hairnet covering his beard because they were out of hairnets. He said they did not have a DM, and supplies have not been consistent. During an observation and interview on 02/26/25 at 12:21 PM, DS C, was observed walking in the main kitchen of the facility without wearing a hairnet. C said he entered from the other door which was why he did not have on a hairnet. DS C said no, it does not mean he should not have on a hairnet when entering the kitchen from another door. DS C said an hairnet should be worn at all times and he forgot to put a hairnet on but he remembered he did not have one on when he saw this surveyor in the kitchen. During an interview on 02/26/2025 at 1:33 PM, the DON said a hairnet should be worn at all times when in the main kitchen and the satellite kitchens. He said when dietary staff are in the kitchen, a hairnet should be worn to cover hair on their head as well as beards. The DON said they are without a DM at the time, but DS C should have been more conscience of a hairnet, because hairnets were just discussed with the staff on 02/25/2025. Review of a policy titled: Orientation and Education, Subject: Dress Guidelines for Food Service Management and Clinical Nutrition Staff. Policy #E007 dated 5/95, revised 1/22. Procedure: Hair restraints are worn by all when in the kitchen. This includes department associates, associates from other facility departments and guests, such as vendors. 455983 Page 6 of 6