Inspection·September 18, 2023

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 help prevent the development and transmission of communicable disease and infections on 2 of 3 ice chest observed for infection control. Residents Affected - Few Ice chest on hall 100 revealed plastic cup stored inside laying on the ice. Ice chest on hall 400 revealed metal scoop inside laying on the ice. This failure placed residents at risk for cross contamination and/or spread of infection that could cause severe illness and decreased quality of life. Observation on 9/18/23 at 08:59 am of ice chest on hall 100 revealed Large Plastic cup inside lying on the ice. No storage container visible on ice chest. Observation on 9/18/23 at 09:17 am of ice chest on hall 400 revealed metal scoop inside lying on the ice. Scoop holder was attached to cart. Observation on 9/18/23 at 11:29 am of ice chest on hall 100 revealed large plastic cup inside lying on the ice. Interview on 9/18/23 at 10:45 CNA A stated he has been with the facility for 1 day (today is his first full day as a qualified CNA). He stated that the ice scoop should be placed in the holder attached to the cooler, not inside the cooler. Interview on 9/18/23 at 12:55 PM CNA B stated she knew the ice chests scoops were not supposed to be kept in the coolers themselves, but in a holster attached to the cart. Interview on 9/18/23 12:30 pm with DON, stated her expectation was that the proper scoop is used to pass out ice and that is be stored in the attached holster when not in use. She stated not using the proper equipment to pass ice and not properly storing the scoop can put the resident at risk for potential harm from cross contamination. Interview on 9/18/23 100 pm with ADM. Stated her expectations was that staff follow policy and procedures for the ice chest and use the proper equipment. She stated that not following the policy and procedure could potentially place residents at harm for illness duet to cross contamination. Record review on 9/18/23 1:15 pm of Policy Cleaning of Ice machine and scoops dated 1/1/10 states (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675201 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 675201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Medical Lodge 300 S. Highway 36 Bypass Gatesville, TX 76528 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)