Health inspection·April 6, 2023

F 0804 could choke and if it was too thin, they could choke. Level of Harm - Minimal harm or potential for actual harm Interview with [NAME] B and Dietary Aide on 04/06/2023 at 10:21 AM revealed [NAME] B stated they usually use a scoop to measure out the thickener and they go by the guide which was printed on the containers. [NAME] B searched for the scooper; however, it was not where he said it should be kept. He asked the Dietary Aide where the scooper was located, and she stated she didn't know where it was either. Dietary Aide stated they did not really need it because they just add the thickener a little bit at a time, until the mixture reaches the desired consistency. She stated they have been doing it so long, they know how it is supposed to look and [NAME] B agreed with her. Dietary Aide then said, You have to be careful when adding the powder because if you add too much, it won't taste like food anymore and it won't be enjoyable for the person eating it. The Dietary Manager then entered and said there used to be a guideline taped to the refrigerator, however, when she retired and returned, it was no longer there. She stated she could pull it up and print it out for me if I wanted to see it. She stated they had just been adding the thickener until it reached the desired consistency. Residents Affected - Some Interview on 04/06/23 at 01:14 PM with Director of Nursing revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated the risk of pureed foods not being the right consistency, would be aspiration. She stated all residents deserve to have a palliative meal. She stated the resident who are on pureed diets, have communication deficits and are not able to voice their displeasure. She stated one day, the dietitian was in the facility, and she was talking with staff at the nurses station about the taste of pureed food. She stated she does not recall them saying anything bad. Interview on 04/06/23 at 01:39 PM with the Administrator revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated if the pureed food is prepared and the cook is not using the correct amount of thickener, it could cause the resident to choke. She stated too much thickener could cause aspiration. She stated it would dilute the nutritional value of food, which would cause weight loss and/or loss of vitamin. She stated residents have a right to receive nutritional food that also tastes good. The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, reflected, Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning and texture. Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 2 of 6 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 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 ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one of the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food containers and cooking products in the kitchen and in the dry food pantry were closed, covered, or sealed properly. 2. The facility failed to ensure the facility's kitchen and dry food pantry were clean of dirt and debris. 3. The facility failed to ensure that staff covered their head and beard while conducting dietary duties. 4. The facility failed to ensure that the dishwasher worked properly. 5. The facility failed to cover the clean bowls and stored in the bowl rack. These failures could place residents at risk for cross contamination and other bacteria illnesses. Findings include: During an observation on 04/04/2023 at 9:32 AM of the initial tour of the facility's only kitchen revealed the [NAME] not wearing a hair or beard restraint. An observation on 04/04/2023 at 9:32 AM revealed the following food in the facility kitchen and dry food pantry not being closed, covered, or sealed properly. Box of Quick Creamy Wheat - partially opened, not in a bag and not resealed Box of Corn Starch - partially open, not in a bag and not resealed Box of Egg Noodles - opened and placed in an unsealed bag Box of [NAME] - opened and placed in an unsealed bag Container of [NAME] Sauce Mix - top of container was not securely fastened Bag of Corn Chips - opened and placed in another bag, which was not closed or sealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 3 of 6 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 Bag of Elbow Macaroni - opened and not closed securely Level of Harm - Minimal harm or potential for actual harm Bag of Fettuccine - opened and placed in a zip lock bag which was not sealed Residents Affected - Many In a continued observation of the of the dry food pantry revealed the dry food pantry had dirt build-up and dried spills on the walking space of the floor and under the racks which held food. The seal of the deep freezer had condensation and a black substance present in the creases. Corn chip crumbs were scattered on the top of the deep freezer. Loose elbow macaroni was observed on top boxes and bags of food on the shelf below the shelf on which it was stored. An observation on 04/04/2023 at 9:41 AM revealed [NAME] B not wearing a beard covering or head covering with beard stubble hair exposing the sides of his beard from the jaw line above the lips up to his earlobe and under his chin. An interview with [NAME] B on 04/04/2023 at 9:41 AM revealed he ran the kitchen when on shift. He stated he had to work alone for a while until he was allowed to bring on another person to assist. He stated he cooked, cleaned, washed dishes, received deliveries, plated the food, and loaded the carts for the halls. He stated when the kitchen aide worked with him, she shared with all tasks except cooking and plating. He stated they did not have a full part time DIETARY MANAGER and they had had about 3 to 4 different DIETARY MANAGERs in about 6 to 8 months. He stated they had a part time DIETARY MANAGER, who was technically retired from the facility, however, she worked at the facility two days a week. An observation on 04/04/2023 at 9:45 AM revealed dirt and debris on the kitchen floor, under all of the raised fixtures in the kitchen. There was also dust build-up and dirt on the two, kitchen window air conditioning units. An observation on 04/04/2023 at 9:47 AM revealed a rack located on the floor, next to the counter, which held the coffee maker. The rack contained stacks of bowls which were turned upside down. The bottoms of the bowls were soiled with dried drippings from splattered coffee, which had. The number of bowls which had been soiled were too numerous to count. An observation on 04/04/2023 at 9:50 AM revealed a box which contained a bottle of cooking oil was located next to the entrance to the kitchen. The bottle of oil was exposed by a cut-out in the box. The opening of the bottle did not have a lid on it. An interview with the [NAME] B on 04/04/2023 at 9:50 AM revealed he had recently used it to cook, however, he had forgotten to put the lid back on it. He proceeded to place a plastic cup lid, which was used to cover the cups of beverages for the residents. This cover did not fit the opening of the cooking oil bottle, it just sat on top and was not secured in any fashion. An observation on 04/05/2023 at 11:04 AM revealed the low temperature dishwasher's thermometer read 50 degrees Fahrenheit and did not appear to be moving while it was in operation. An interview and observation on 04/05/2023 at 11:08 AM revealed [NAME] C stated the hot water will only stay hot if they have the hot water running from the faucet of the sink located across from the dishwasher. Which at the time of this interview, the hot water was observed to be running from the faucet at that sink. She stated the machine is old and it has been worked on several times. She stated several parts had been replaced. She stated the hot water heater had been reset and the machine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 4 of 6 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 was still not able to run hot water without having the hot water running from the faucet on at the sink. She stated the maintenance director instructed them to use the phone number on the dishwasher, to contact the manufacturer if the thermostat stopped working or if the water stopped getting hot. An observation on 04/05/2023 at 11:16 AM revealed after Dietary Aide raised the cover of the dishwasher 4-5 times, and each time it was raised, the temperature would go up. Dietary Aide stated by lifting the cover, it restarted the cycle which they found would increase the temperature. The thermostat did rise to 118 degrees Fahrenheit. An observation on 04/06/2023 at 10:21 AM revealed the floor of the kitchen still had the same dirt and debris present under all raised fixtures. A drinking cup and desert bowl were on the floor, under a sink adjacent to the dishwasher. The top of the dishwasher case was covered in dust, crumbs, and debris. The bracketed shelves where labels and the thickeners, container labels, litmus test strips, and other miscellaneous items were stored, was covered with dried brown splatter spots. An open container of powered food thickener was on the shelf. This open container was also observed on 04/05/23, being used when [NAME] A was preparing pureed chicken. There was also an open container of liquid food thickener on the shelf. The safety seal was partially opened, and it had dust build-up on it. The box which contained a bottle of cooking oil was located next to the entrance to the kitchen. The bottle of oil was exposed by a cut-out in the box. The opening of the bottle did not have a lid on it. When asked if it was being used or had recently been used, the [NAME] B said he forgot to put the lid back on it and proceeded to place a plastic cup lid, which was used to cover the cups of beverages for the residents. This cover did not fit the opening of the bottle, it just sat on top and was not secured in any fashion. An observation on 04/06/2023 at 10:51 AM revealed the dry food pantry's walking space of the floor had been mopped, however, dry spills and dirt build-up was still under the shelves which held the food. The open containers and packages of food were still not closed properly. An interview on 04/06/2023 at 12:06 PM revealed the DIETARY MANAGER stated if the dishwasher did not reach around 70 degrees Fahrenheit and the chemical sanitizer levels were not good, it would mean the dishes and utensils were not getting properly cleaned, which would mean they were not safe for the residents to eat from. An interview on 04/06/2023 at 1:03 PM revealed [NAME] B stated hair coverings are to be worn at all times. He stated he usually wore a nylon cap; however, he would get too hot while wearing it and he would take it off when he got too hot and started to sweat. He stated if head and beard coverings were not worn, hair could fall in the food. Observation and interview on 04/06/23 at 1:17 PM revealed the Dietary Aide was wearing a hair net, however, hair was uncovered around the perimeter of the cap. When the exposed hair was mentioned to her, she stated her hair did what it wanted to do and she couldn't control it. She did not attempt to correct the issue, until the ADietary Managerinistrator interceded and instructed her to do so. An interview on 04/06/23 at 1:28 PM revealed [NAME] B stated the maintenance guy is always working on the dishwasher. He stated it had had issues for a long time, about 3-4 years. He stated the hot water issue, with them having to turn the hot water faucet, at the sink across from the it, had been going on for about a month. An interview on 04/06/2023 at 1:43 PM revealed the ADietary Managerinistrator stated an unclean (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 5 of 6 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 675151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Care Center 632 Windsor Way Van Alstyne, TX 75495 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 kitchen could cause cross contamination for the food being prepared for the residents. She stated the open containers of food could be contaminated with dust and insects. She stated the open containers of food thickener were unacceptable. The policy which was provided by the Dietary Manager for the facility was The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, which reflected, During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent food borne illness. Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning and texture. Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents. All working surfaces, utensils, and equipment are cleansed thoroughly and sanitized after each period of use. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Tightly seal opened packages to prevent contamination or place food in covered containers. Clean exterior surfaces of food containers, such as cans or jars of visible soil before opening. Dishes, flatware, and glassware are free from chips, cracks, or stains. Anyone working in the kitchen during normal food production hours is expected to wear appropriate hair restraints (such as hats, hair covers or nets, beard restraints). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675151 If continuation sheet Page 6 of 6