Health inspection·January 17, 2025

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 safety in the facility's only kitchen. Residents Affected - Many The HR staff was not wearing hair restraints while in the kitchen. The trashcan next to the handwashing station was overflowing and without liner. The Ice machine was dirty. An open and overflowing trash container was stored next to the ice machine. The ice scoop was stored with the mop pads, mop bucket, and brooms located over the Ice machine. The [NAME] failed to change gloves and perform hand hygiene after touching the trash can lid. The dishwasher water temperature was below the recommended temperature. The facility did not document temperatures for the food, dishwasher and refrigerators. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Finding included: Observation on 01/17/2025 at 09:35 am revealed the following: *The HR staff in the kitchen, was not wearing her hair restraint properly. The HR staff hair was outside of the hair restraint from the back of her head to her neck area. *The trashcan next to the handwashing station was overflowing with trash and there was no liner in the trashcan. *The ice machine in the kitchen had black, white and greenish-like substances covering the inside and the edges of the machine and the lid. The HR staff wiped the ice machine lid with her finger and her finger became black. *A 32-gallon trashcan full to capacity, no top, was next to the ice machine. *A 4-tier mental shelve with multiple mop heads and a bucket containing the ice machine scoop next to the ice machine. Observation on 01/17/2025 at 10:15 am revealed the AD was operating the dishwasher. The wash temperature got to 102-degree Fahrenheit the first time and 110 degrees the second time. There was a sign by manufacture posted on the dishwasher indicating the minimum water temperature was 120-degree Fahrenheit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 2 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 Review of facility's clipboard with temperature logs reflected the following: Level of Harm - Minimal harm or potential for actual harm *The test strip log for 3-compartment sink last log dated 10/17/2024. *The refrigeration temperature last log dated 10/17/2024. Residents Affected - Many *The Hot beverage temperature log for the month of December 2024 and was blank . *There were no temperature logs on the clipboard for holding of cold food, hot food, and holding temperatures. Observation on 01/17/2025 at 11:40 am revealed the [NAME] touched the trash can lid while putting trash in the container, did not change gloves or perform hand hygiene. The [NAME] used same soiled gloved hands to touch already cook chicken to put on the tray for re-heating. The [NAME] then removed gloves, performed hand hygiene, donned clean gloves, opened the oven and place the tray of chicken in the oven. The [NAME] with now soiled gloved hands from touching the oven, touch the biscuits by putting in the pan to serve. During an interview on 01/17/2025 at 1:29 pm, the DA stated she had been at the facility since 12/30/2024. She stated there had not been a dietary manager since she had been hired and the HR staff had been managing the kitchen. The AD stated she was trained by CMA A on how to operate the dishwasher. She stated the temperature for the dishwasher should reach 170 degrees and if the temperature was below the recommended temperature, the dishes would not be disinfected and that would impact the residents. She stated the dishwasher machine had been broken for couple of days and the HR staff was made aware. The DA stated she had not been documenting the dishwasher temperature. She stated, she had not seen the cooks check the food temperatures before today. The DA stated she realized the trash bin next to the ice machine was overflowing and was too close to the ice machine along with the mop bucket and mop heads. She stated the trash can, mop bucket and mop head had been in that location since she started at the facility, and it was not appropriate to keep the trash can next to the ice machine due to cross contamination. The AD stated the ice machine looked dirty, with a lots of build up on it. She stated she was in-serviced on 01/15/2025 on washing hands continuously, wearing gloves, changing gloves, washing hands with each glove's changes. She also stated they were in-serviced on temperature logs being required for the dishwasher, the food, refrigerator and assumed it was for sanitation reason. Stated the HR staff came up with schedule for cleaning the kitchen. She stated she knew hand hygiene was important to keep the residents from being sick. During an interview on 01/17/2025 at 1:50 pm the [NAME] stated he had been at the facility for 4 days but had been a cook for a while and was not familiar with the steam table. He stated he knew to wash hand when changing gloves, change gloves from one task to the other, wear gloves when handling food. He stated he should have changed his gloves and perform hand hygiene when he tapped the trash can lid due to infection control. He stated he should have changed gloves and performed hand hygiene when he touched the oven before touching the biscuits. The cook stated the black, white and greenish colors on the ice machine looked like mold and did not think it was safe for the residents to drink from due to infection control. The cook stated the overflowing trash next to the ice machine was not sanitary and the residents could get sick from that. The [NAME] stated he was aware that he had to check food temperatures after cooking and while on the steam table but did not know he had to log the temperatures. The cook stated he did not know they had to log the refrigerators temperatures also. He stated he had never seen temperature logs and had not log food or refrigerator temperatures. He stated the kitchen staff attended a meeting on 01/15/2025 and it was discussed the dishwasher (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 3 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 - Many machine temperature was not getting to the right temperature but was not sure what was done to fix it. He stated the dishwasher not getting to the right temperature could impact the residents because the temperature was not hot enough to clean the dishes and kill the bacteria, residents could get sick. The cook stated the trash in the kitchen was from the night. During an interview on 1/17/2025 at 2:21 pm, CMA A stated she was a CMA and there was no position for CMA in the facility at the moment, so she was helping out in the kitchen due to previous experience as a cook and dietary manager. CMA A stated the kitchen was filthy, food consistency was out of control, so she tried to train the [NAME] on her off days. CMA A stated she notified the acting HR staff who was the acting dietary manger on Monday 01/13/2025 that dishwasher machine had problems and the water was not getting hot enough. CMA A stated the HR staff stated she was aware of the situation and Corporate was getting a plumber to the facility to adjust the water temperature. CMA A stated the dishwasher machine water not getting hot enough could cause the dishes, utensils and cookware not to properly be clean or sanitized and can lead to bacteria and make residents sick. CMA A stated the [NAME] and other dietary should be responsible to clean, but it was not being done. She stated there was no cleaning schedule or log in the kitchen. CMA A stated the black, white and greenish substances on the ice machine looked disgusting, appeared to be mold or mildew and calcium build up. She stated the trash can next to the ice machine looked like it had not been cleaned for years. She stated they had always stored the dirty linen basket and the mop head next to the ice machine. She stated those things should not be stored next to the ice machine. During an interview on 1/17/2025 at 3:15 pm the Maintenance Director stated he had been employed at the facility for about a week. He stated he was not made aware of the dishwasher water temperature not getting to the appropriate or recommended temperature. The maintenance Director stated he would have turned on the temperature from the water heater if he had known He also stated it was important to keep the dishwasher water temperature at the recommended temperature to keep germs down and prevent the residents from getting sick. During an interview on 1/17/2025 at 3:43 pm, the HR staff stated she was not in charge of dietary, there has been no one in charge of the kitchen, she was just helping out as needed. The HR staff stated the dietary staff were checking food and refrigerator temperatures but were not logging it. She stated she in-serviced dietary staff on food and refrigerator temperatures. The HR staff stated she knew there was a problem with the sprayer on the sink and the maintenance from corporate was in the facility to adjust the water heater temperature. The HR staff stated she was not aware that the dishwasher water temperature was not getting to the right or appropriate temperature. She stated the dishwasher water not getting to the right temperature would cause the dishes not to be sanitize properly, bacteria would build up and she would not want to eat from a dirty plate. The HR staff stated the black, white and greenish substance on the ice machine, she was assuming it was dirt or grime, the lid was dirty, in the machine was stained. The HR staff stated, sanitation wise, the trash, mop bucket and head should be kept separately from the ice machine. She stated the ice machine should be clean once a month. She stated she printed out a cleaning schedule the day before and was supposed to post the schedule the day of the investigation. The HR staff stated she was adjusting her hair restraints when the surveyors got to the kitchen. She stated all of staff hair should be in the restraint to prevent hair from going into the resident's food. During an interview on 1/17/2025 at 4:10 pm the DON stated the facility had been out of a Dietary manager since the middle of December 2024 and the HR staff had been managing dietary, the schedule and training until they can get a new manager for the kitchen. She stated the interim Administrator started 01/06/2025 and there have been all new staff. The DON stated, Hand hygiene was performed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 4 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 - Many anytime the staff change gloves, between task, when visibly soiled, after the restroom, from raw to cook change gloves and hand hygiene to prevent cross contamination and the spread of bacteria and viruses. She stated if the staff touched the touched the trash can with his gloved hands, he should have changed the gloves, performed hand hygiene, and wore clean gloves to prevent cross contamination. The DON stated the ice machine was gross, the trash can next to the ice machine was overflowing and touching the ice machine, the trash can, mob bucket and mop head should not be in that space due to cross contamination and infection. She stated the night shift in the kitchen were supposed to take the trash out. The DON stated the dietary staff were supposed to check food temperature to make sure it was not cold to grow bacteria or hot to burn the residents. The DON stated the dietary staff were supposed to log food, refrigerator, and dishwasher temperatures. The DON stated the recommended temperature for the dishwasher was on the dishwasher. She stated the facility had issues with their hot water and the maintenance from corporate was in the facility to fix it. The DON stated she was aware there was an issue with the dishwasher water not getting to the recommended temperature and she told the HR staff because she was in charge of dietary. The DON stated, If the water is not getting hot enough, you will run a problem of not being disinfect, running the risk of passing out infection from one resident to the other. During an interview on 01/17/2025 at 5:26 pm the Interim Administrator stated he had been in the facility for about 2 full weeks. He stated he had not been made aware that the dishwasher water was not reaching the appropriate temperature. He stated it was his expectation that staff let him know whenever something was broken. The interim Administrator stated it was a problem that the dishwasher water was not reaching the appropriate temperature, the dishes were not being sanitized appropriately and pathogens would build up. He stated the facility would have it fixed. The Surveyors requested document for the hot water heater being fixed and the interim Administrator stated he would get it to the survey team by 01/21/2025. The survey team did not get the documentation. Review of facility's document provided titled Ware washing in-service undated reflected: Low Temperature Dish Machine---Low temperature machines using chlorine as a chemical sanitizer should have a concentration between 50pm and 100ppm and be measured using the appropriate chemical test kits. o The wash & rinse cycle must maintain a minimum temperature of 120o. o Can damage flatware and plastics if chemicals are used at elevated concentrations. o Require the use of proper chemical test strips to measure the chemical concentration. Dishwashing Procedure Check to make sure machine is performing properly, reaching minimum temperatures & sanitizer ppm before starting procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 5 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 Monitoring Requirements Level of Harm - Minimal harm or potential for actual harm To ensure that the dishwasher is running effectively, monitor the following: Residents Affected - Many Temperature: If the temperature doesn't reach the required minimum, then dishes are not being properly cleaned, which can lead to risk of food borne illness. Chemical Levels: If the chemicals for low temperature machines don't reach their required minimum, then dishes aren't being sanitized, which can lead to risk of food borne illness. A lowtemp system washes and rinses dishes at 120°F or higher and rinses them with a chemical sanitizing solution to neutralize any remaining bacteria or pathogens. Review of facility's Policy titled Food Handling revised June 1, 2019 reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be handled according to the state and US Food Codes and HACCP guidelines. 1. General Guidelines a. Use clean, sanitized surfaces, equipment and utensils. b. Wash hands properly before beginning food preparation. c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. d. Do not let surfaces, equipment or utensils that have been in contact with raw meat to come into contact with other food unless the items have been cleaned and sanitized first. e. Do not bring soiled food carts, food equipment or garbage containers through the food preparation area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 6 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 - Many Review of facility's policy titled Mechanical Cleaning and Sanitizing of Utensils dated October 1, 2018, reflected: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 1. Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions 5. If a machine that uses chemicals for sanitizing is in use, follow these guidelines: a. The temperature of the wash water must be at least 120°F. Review of facility's policy titled Refrigerator and freezer Temperature revised June 1, 2019, reflected: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. . Place a thermometer inside freezers near the door where the temperature is warmest. Check the temperature of all freezers using the internal thermometer to make sure the temperature stays at 0°F or below. Temperatures should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the freezer. Review of facility's policy titled Taking Temperatures-Nutrition and Food Service Policies and Procedures Manual dated 2018 reflected: The facility realizes the critical nature of serving foods at the correct temperatures to ensure the health of its residents. The facility will take and record the temperatures of all foods prior to service. Foods not at the correct temperature will be corrected or discarded as necessary. Review of facility's policy titled Handwashing/Hand Hygiene revised 1/20/2023 reflected: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 7 of 8 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 675076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Llano Nursing and Rehabilitation Center 800 W Haynie St Llano, TX 78643 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 5. Level of Harm - Minimal harm or potential for actual harm Hand hygiene must be performed prior to donning and after doffing gloves. 6. Residents Affected - Many Hand hygiene is the final step after removing and disposing of personal protective equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675076 If continuation sheet Page 8 of 8