Health inspection·April 27, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 19 residents reviewed for resident rights. (Resident #13, Resident # 28, and Resident #31) The facility did not ensure Resident #13, Resident #28, or Resident #31 were assisted with eating their lunch meal in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: 1.Record review of Face Sheet dated 4/27/22 indicated Resident #13 was [AGE] years old and admitted on [DATE] with diagnoses including: unspecified dementia with behavioral disturbance (behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, wandering, and hoarding), Peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and hypertension (a condition in which the force of the blood against the artery walls is too high) Record review of most recent MDS dated [DATE] indicated Resident #13 usually made himself understood, and usually understood others, and had severe cognitive impairment with BIMS of 07. The MDS indicated Resident #13 required limited assistance with ADL's. Record review of care plan dated 2/27/22 indicated Resident #13 had an altered nutritional status and had a need for assistance/cueing with meals. It indicated he would receive necessary assistance with food and fluids over the next 90 days. The intervention was to provide assistance with food and fluids. During an observation on 04/25/22 12:12 PM CNA G stood beside Resident #13 who was seated in a chair in front of the table and tried to give him a bite of food, and he shook his head and refused. 2.Record review of Face Sheet dated 4/27/22 indicated Resident #28 was [AGE] years old and admitted on [DATE] with diagnoses including: wedge compression fracture (this fracture usually occurs in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and hydronephrosis (a condition characterized by excess fluid in a kidney Page 1 of 19 675230 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0550 due to a backup of urine). Level of Harm - Minimal harm or potential for actual harm Record review of the most recent MDS dated [DATE] indicated Resident #28 was able to make herself sometimes understood, sometimes understood others and had severe cognitive impairment with a BIMS summary score of 0. The MDS indicated Resident #28 required extensive assistance with eating. Residents Affected - Few Record review of the care plan dated 4/15/22 indicated Resident #28 had an altered nutritional status and had a need for assistance due to dysphagia and chewing difficulties/cueing with meals. It indicated she would receive necessary assistance with food and fluids over the next 90 days. The intervention was to monitor oral intake of food and fluid. During an observation on 04/25/22 at 12:05 PM ADON stood over Resident #28 while she was in her wheelchair encouraging her to eat and gave her a bite while standing over her. During an observation on 04/25/22 at 12:07 PM ADON walked back by encouraging Resident #28 to eat a bite and gave her a bite while standing over her. During an observation on 04/25/22 at 12:09 PM ADON walked back over to Resident #28 encouraging her to eat and gave her a bite standing up beside her. 3.Record review of Face Sheet dated 4/27/22 indicated Resident #31 was [AGE] years old and admitted on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance (it is a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), and history of falling. Record review of the most recent MDS dated [DATE] indicated Resident #31 was able to make herself understood, usually understood others and had moderate cognitive impairment with a BIMS summary score of 11. The MDS indicated Resident #31 required supervision with eating. Record review of the care plan dated 4/15/22 indicated Resident #31 had an altered nutritional status and had a need for assistance/cueing with meals. It indicated she would receive necessary assistance with food and fluids over the next 90 days. The intervention was to monitor oral intake of food and fluid. During an observation and interview on 04/25/22 at 12:33 PM CNA J stood over Resident #31 feeding her in her room. Resident #31 was in her wheelchair and food was on the bedside table. CNA J stood beside Resident #31 feeding her directly in front of her roommate who was seated in a chair feeding herself. CNA J said that she was feeding Resident #31 while she stood. During an interview on 04/27/22 at 9:15 AM with CNA J, said staff were trained on the appropriate way to assist a resident with eating. She said while assisting Resident #31, she should have sat in a chair to assist her. She said staff should sit while assisting so Residents don't feel like you are in a hurry to assist. CNA J said she stood to feed Resident #31 because there was not enough space to put a chair to sit in. During an interview on 04/27/22 at 10:38 AM with CNA G, she said staff should sit beside a resident when helping them eat. She said staff should never stand so that staff have the right angle and not put too much food in their mouth. She said staff should not stand because it would make residents 675230 Page 2 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0550 Level of Harm - Minimal harm or potential for actual harm feel like they were being forced and she (CNA G) wouldn't like somebody standing over her. She said if staff sit down and talk to a resident they may eat more. CNA G said she should not have stood beside Resident #13 and gave him a bite. She said staff were trained on the appropriate way to assist a resident with eating. CNA G said she was standing when she gave him a bite, because she was just trying to get him to eat a little more. Residents Affected - Few During an interview on 04/27/22 at 10:15 AM with ADON, she said staff were supposed to sit down while assisting a resident with eating. She said some with dementia have to be encouraged to eat more and sometimes if you talk to them a little bit they will eat more. She said that she should have sat down when she was assisting Resident #28 with eating. She said you should be at eye level when you are assisting a resident. ADON said you are at eye level so they can see you and you are not standing over them putting food in their mouth. She said staff were trained on how to assist a resident with eating. ADON said CNA's were trained to sit to assist a resident with eating. She said if she saw a staff feeding a resident standing, she would redirect them to sit. ADON said she did not see CNA G standing over Resident #13, but if she did, she would have redirected her to sit had she seen it. ADON said she stood because she was trying to assist multiple residents with their needs. During an interview on 04/27/22 at 11:37 AM with DON said staff were supposed to sit down when feeding a resident and staff should be eye level or below and this was done so they feel equal to you. DON said residents were not as comfortable if staff were standing up. DON said staff had received training on proper way to assist a resident with eating and they were re-in-servicing right now. During an interview on 04/27/22 01:43 PM with Administrator, he said he would expect a staff to be seated in most instances when assisting a residence with feeding. Administrator said he would expect staff to do whatever promotes the most dignity for a specific resident regarding whether they were sitting or standing while feeding. Administrator said with Resident #31 staff should have been sitting. Administrator said with Resident #13 he can feed himself and understand more and there were times that his abilities fail. Administrator said verbal cues were okay standing with Resident #13, but if they were assisting with eating staff would need to be seated. Administrator said he would expect staff to be seated while feeding Resident #28. Administrator said staff were trained to be seated at eye level while feeding a resident. Administrator said a staff being seated was a safety and dignity issue. Administrator said for example if a resident choked a staff would need to be seated so they would know that a resident was having an issue. An undated Statement of Resident Rights policy indicated, If anyone hurts you, threatens you, neglect your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Human Services by calling [PHONE NUMBER] you have a right to be treated with courtesy, consideration and respect . Review of a Policy dated 2/12/20 Assisting Residents with eating indicated, Qualified nursing staff will assist the resident who is unable to feed self in order to promote adequate nutrition and to help the resident enjoy a satisfying meal .sit down if possible . 675230 Page 3 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source are reported immediately or not later than 24 hours for 1 of 19 residents reviewed for abuse and neglect. (Resident #36) Resident #36 sustained an injury of unknown source that was not reported timely as required. This failure could place residents at risk for abuse and neglect. Findings included: Record review of consolidated physician orders dated 4/27/2022 indicated Resident #36 was [AGE] years old and admitted on [DATE] with diagnoses chronic obstructive pulmonary disease (lung disease), Alzheimer's (dementia), and heart disease. Record review of the MDS dated [DATE] indicated Resident #36 was rarely/never understood and rarely/never understood others. A BIMS (Brief Interview for Mental Status) was not conducted due to Resident #36 being rarely to never understood. The MDS indicated Resident #36 required extensive assistance with ADLs. Record review of a care plan dated 3/2/22 indicated Resident #36 had a cognitive deficit. The care plan indicated the resident missed intent/part of messages at times and had trouble expressing self at times. Record review of nurse's note in the electronic chart for Resident #36 dated 3/18/2022 at 11:22 AM revealed, CNA A reports that while getting resident up and dressed, she noticed bruise to the left eye and notified the nurse. Bruise is 3x1 on upper eyelid. Resident was observed by this nurse rubbing both eyes several times, upon further investigation, noted bruising to left side of forehead above eye measuring 2x1. It appears resident bumped her head against something, possibly the wall that her bed is against, and bruising went down into eyelid. She appears unafraid. She is alert and confused, as is her norm. Family member notified, who stated that resident keeps a bowl of snacks by her bed and could have bumped her head against that table while getting a snack. Will be getting witness statement from 10-6 shift. Will monitor area until resolved. MD notified with n/o (new order) for CBC. DON notified. Neuros started. The note was signed by LVN B. Record review of the facility's Incident/Accident Report dated 3/18/2022 for Resident #36 revealed, .Type of Incident - Bruise/discoloration - left eyelid, left forehead .Witnesses - No .Injury Report - Type of Injury Bruise/discoloration .Description of Incident - 6-2 CNA A noted bruise to resident's left eye when she was getting her up and dressed. Notified LVN C. Resident was observed rubbing her eyes several times but does not have the cognitive ability to tell us how she obtained the bruise. Upon further inspection noted bruise to left side of forehead just above eye. It appears she bumped head and bruising to eye is result of was completed by the Administrator on 3/31/2022 at 3:14 PM. Record review of a Witness Statement by NCNA (Non Certified Nurse's Aide) H, dated 3/18/2022 675230 Page 4 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed, .Date of Accident/Incident 3/17/2022 .When I came in March 17, 22 to work A Hall doing my first round, I noticed a bruise on Resident #36's left eye . The witness statement was signed by NCNA H. During an interview on 04/26/22 at 3:52 p.m., LVN C revealed she was the one that assessed Resident #36 on 3/18/2022. She said the bruising was on her forehead just above her left eye and went down onto her left eye. She said because the resident's cognition ability she was unable to say what happened to her eye. LVN C said she notified the DON. During an attempted interview on 4/27/22 at 8:30 a.m., revealed Resident #36 was unable to answer questions concerning the incident from 3/18/2022. During an interview on 4/27/22 at 8:52 a.m., the DON revealed the injury to the face of Resident #36 on 3/18/2022 was not reported to the state because of her anemia. She said the resident was unable to communicate what happened to her eye. She said the injury consisted of a bump on her forehead a small area of a purple discolored are to her eyelid. She said the injury was not a bruise. She said she did not report this injury because she was pretty sure of what happened. She felt the injury was not unknown even though the resident cannot verbalize what happened. She said a family member had suggested that maybe Resident #36 had bumped her eye. She said she believed this to be true because of the resident's history. She said the resident had bruising to her arm previously from a blood pressure cuff. She said she did not know at the time that the injury on 3/18/22 was considered an injury of unknown origin. The DON did agree an injury of the face was a suspicious injury. She said the Administrator was the Abuse Coordinator. During an interview on 4/27/22 at 1:41 a.m. The Administrator revealed he was notified of the injury to the left eye by a family member of Resident #36. He said he was unsure of the date the family member reported the injury to him. He said he did not report the injury to the state because the family member told him they were not concerned about the injury. He said, We do not have a ton of self-reports and the family member wanted me to know that she wasn't concerned. He said he did not attempt to interview Resident #36 because she was non-interviewable and the family member was her legal advocate. He said normally this type of injury would be concerning to him but since the family member said they were not worried about it, he did not feel it needed to be reported. He said injuries of unknown origin should be reported within 24 hours. Review of a facility Abuse Prohibition Management Program - Screening, Training, and Prevention Policy dated 9/1/2005 indicated, .When an alleged or suspected case of mistreatment,, neglect, injuries of unknown source, or abuse is reported the facility administrator, or his/her designee, will notify the following persons or agencies of such incident; the State licensing/certification agency responsible for surveying/licensing the facility .The facility's Administrator, and in his/her absence, the Director of nursing will perform the duties of the Abuse Prevention Coordinator. Duties include .assuring that the timely identification, investigation, and report of incidences .the Abuse Prevention Coordinator will immediately report to the State Agency and other appropriate authorities, incidents of resident abuse as required under applicable regulations and regulatory guidance . 675230 Page 5 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents who were unable to carry out activities of daily living with the necessary services to maintain good personal hygiene for 2 (Resident #15 and Resident #50) of 19 residents reviewed for ADL care. Residents Affected - Few The facility failed to remove unwanted facial hair from Resident #15 and Resident #50. The facility failed to provide scheduled bath/showers for dependent Resident #50. This failure could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of the consolidated physician orders dated 4/27/22 revealed Resident #15 was [AGE] years old, female and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease), dementia, muscle weakness, muscle wasting and atrophy (shortening). Record review of the MDS dated [DATE] revealed Resident #15 was usually understood and usually understood others. The MDS revealed Resident #15 had a BIMS score of 7 which indicated severe cognitive impairment and required extensive assistance-total dependence for ADLs. The MDS revealed Resident #15 rejected evaluation or care 1 to 3 days but had improved current behaviors and care rejection from prior assessment. Record review of the undated care plan revealed Resident #15 had cognitive deficit with decision making, misses intent/part of message at times and trouble expressing herself at times. The care plan revealed Resident #15 had self-care deficit related to fluctuating cognition and diagnoses. Goal to maintain or improve self-cared area of dressing, grooming hygiene, and bathing over 90 days. Interventions of aid with self-care as needed. The care plan revealed Resident #15 required full weightbearing due to impaired physical mobility. No documentation of rejection of care or evaluation. Record review of the ADL flow record dated April 2022 revealed Resident #15 received extensive-total dependence for personal hygiene 26 out 26 days. The ADL flow record dated April 2022 revealed Resident #15 received extensive-total dependence for bathing 10 out 13 scheduled days. No documentation of rejection of care. Record review of the B hall bath schedule dated 3/25/22 revealed Resident #15 scheduled bath days were Tuesdays, Thursdays, and Saturdays on the 6am-2pm shift. 2. Record review of the consolidated physician orders dated 4/27/22 revealed Resident #50 was [AGE] years old, male, and admitted on [DATE] with diagnoses including Parkinson's disease (nerve cell damage in the brain), weakness, chronic kidney disease, abnormal gait (manner of walking) and mobility, and type 2 diabetes. Record review of the MDS dated [DATE] revealed Resident #50 was usually understood and usually understood others. The MDS revealed Resident #50 had a BIMS score of 7 which indicated severe cognitive impairment and required extensive assistance to total dependence for ADLs. The MDS revealed Resident 675230 Page 6 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0677 #50 did not reject care or evaluation. Level of Harm - Minimal harm or potential for actual harm Record review of the undated care plan revealed Resident #50 had cognitive deficit effecting decision-making, misses intent part of message at times and expressing self-related to dementia as evidence by short term memory loss. The care plan revealed Resident #50 had self-care deficit related to diagnoses and limited joint mobility which interferes with dressing and hygiene. Goal to maintain or improve self-care of dressing, grooming hygiene, and bathing over the next 90 days. Intervention included aid with self-care as needed and prefers bath in the morning. Residents Affected - Few Record review of the ADL flow record dated February 2022 revealed Resident #50 received extensive assistance to total dependence for personal hygiene 28 out of 28 days and 4 out of 12 days for bathing. Record review of the ADL flow record dated ADL flow record dated March 2022 revealed Resident #50 received extensive assistance to total dependence for personal hygiene 30 out 31 days and 4 out of 15 days for bathing. Record review of the ADL flow record dated April 2022 revealed Resident #50 received extensive assistance to total dependence for personal hygiene 25 out of 26 days and 9 out of 13 days for bathing. Record review of the B hall bath schedule dated 3/25/22 revealed Resident #50 bath days were Tuesdays, Thursdays, and Saturdays on the 2pm-10pm shift. During an observation and interview on 4/25/22 at 10:03 a.m., Resident #50 was sitting in his wheelchair talking to a family member with facial hair. Resident #50 said he had not had a shower in 3 days and could not remember his scheduled days. Resident #50 said he liked to be clean shaved. During an observation and interview on 4/25/22 at 2:19 p.m., Resident #15 was lying in bed reading a book. Resident #15 had frizz, disheveled hair, and hair on her upper lip. Resident #15 was hard of hearing and only nodded her head when questions were asked. During an interview and observation on 4/26/22 at 11:54 a.m., Resident #50 was sitting in his wheelchair looking out the window. Resident #50 still had facial hair. Resident #50 said he got a shower last night and would have liked his beard shaved. He said it was starting to itch and get irritating. Resident #50 said he did not know why the CNA did not shave him. During an observation on 4/26/22 at 3:45 p.m., Resident #15 was asleep in her bed. She had frizz, oily hair with hair on her upper lip. During a phone interview on 4/26/22 at 3:53 p.m., the family member of Resident #15 said she got showers at least twice a week but could not remember the days. She said her and her other family members had to remove Resident #15's facial hair before. The family member said she had not been able to visit in 3 weeks due to other family obligations. She said Resident #15 would not like to have facial hair. The family member said she sometimes refused shower but would normally accept bed baths. During an interview on 4/27/22 at 9:15 a.m., CNA J said she has worked at the facility for 7 years. She said her duties included bathing, showering, and feeding residents. CNA J said Resident #15 scheduled shower days were Mondays, Wednesdays, and Fridays on the 6-2pm shift. She said CNAs were responsible for removal of facial hair. CNA J said she did not work last Friday to know if Resident #15 675230 Page 7 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a bed bath and facial hair removal but Resident #15 had upper lip hair on Monday. CNA J said Resident #15 does not refuse facial hair removal. She said she gave Resident #15 a bath on Monday and planned to go back to remove her facial hair but got tied up. CNA J said Resident #15 should not have facial hair and it could be embarrassing to the residents to have it. She said she was trained to remove facial hair with each shower/bath day. CNA J said Resident #50 requires assistance with his ADLs. She said Resident #50 gets his shower on the evening shift but could not remember what days. CNA J said he did have a beard the last three days and should not have it if he got showered. She said Resident #50 liked to be cleaned shaved and would not want his facial hair. CNA J said Resident #50 having facial hair probably makes him feel unkempt. During an interview on 4/27/22 at 10:15 a.m., the ADON said she had been working at the facility since 1994. She said Resident #50 was a neat man and would rather be cleaned shaved. The ADON said if Resident #50 had facial hair, he was not getting his showers or not getting shaved on shower days. She said she did not know if Resident #15 would let CNAs remove her facial hair, but she did prefer bath bed instead of showers. During an interview on 4/27/22 at 10:38 a.m., CNA G said she had worked at the facility for 5 years. She said her duties included making beds, take care of daily tasks, feeding residents, and providing ADLs assistance. CNA G said she had bathed Resident #15 but not Resident #50. She said the couple of times she gave Resident #15 a shower, she did have upper lip hair. CNA G said she did not shave Resident #15 facial hair with her shower. CNA G said Resident #50 liked to be clean shaved and stayed on top of his hygiene. She said if Resident #50 had facial hair then staff was no aiding with his ADLs. During an interview on the 4/27/22 at 11:37 a.m., the DON said she had worked at the facility for 8 years. She said her duties included incidents and accidents, coordinate infection control, and oversee nursing staff and CNAs. The DON said she expected ADL assistance to be resident driven. She said some residents prefer baths every other day and others like it once a week. The DON said the scheduled bath/shower days was on the computer system and posted on the door. She said staff should document when a resident was showered and if they refused. The DON said there was no separate documentation for shaving or nail care it should be included with baths and showers. She said if a resident consistently refused, it would be in their care plan. The DON said staff should be documenting if the resident does not want facial hair removal. During an interview on 4/27/22 at 1:43 p.m., the Administrator said he had worked at the facility for 3 years. He said he expected residents to received showers/bed bath on their scheduled day. The Administrator said if a resident refused it should be documented by the CNAs and reported to the nurse then placed on the care plan and 24 hours report sheet. Record review of a facility bathing policy dated 2/12/20 revealed .staff will provide bathing services for residents within standard practice guidelines .assist resident with bathing .in the event of refusal or behaviors associated with bathing .to assist with managing behaviors . 675230 Page 8 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for 1 of 19 residents reviewed for accidents. (Resident #50) The facility failed to ensure Resident #50 was transferred with a gait belt. This failure could place resident at risk of injury, pain, hospitalization, and a diminished quality of life. Findings included: Record review of the consolidated physician orders dated 4/27/22 revealed Resident #50 was [AGE] years old, male, and admitted on [DATE] with diagnoses including Parkinson's disease (nerve cell damage in the brain), weakness, chronic kidney disease, abnormal gait (manner of walking) and mobility, and type 2 diabetes. Record review of the MDS dated [DATE] revealed Resident #50 was usually understood and usually understood others. The MDS revealed Resident #50 had a BIMS score of 7 which indicated severe cognitive impairment and required extensive assistance to total dependence for ADLs. The MDS revealed Resident #50 required extensive assistance with two persons assist for transfer and bed mobility. The MDS revealed Resident #50 was not steady, only able to stabilize with staff assistance for moving from seated to standing position, moving on and off toilet, and transfer between bed and chair or wheelchair. Record review of the undated care plan revealed Resident #50 had cognitive deficit effecting decision-making, misses intent part of message at times and expressing self-related to dementia as evidence by short term memory loss. The care plan revealed Resident #50 had self-care deficit related to diagnoses and limited joint mobility which interferes with dressing and hygiene. Goal to maintain or improve self-care of dressing, grooming hygiene, and bathing over the next 90 days. The care plan revealed Resident #50 had impaired physical mobility related to history of Parkinson's disease, cardiovascular (heart) disease, limited joint mobility cause resident to have a higher risk of falling, and limited joint mobility interferes with walking as evidence by assist rails, use of wheelchair, extensive assistance with ADLs, generalized weakness, right upper extremity weakness, right hip joint pain, right knee joint pain, and left hip joint pain. Goal to maintain or improve physical function in bed mobility, transfer, ambulation, locomotion, and range of motion over the next 90 days. Intervention included provide appropriate level of assistance to promote safety of resident. Record review of the ADL flow record dated 4/2022 revealed Resident #50 required extensive assistance (while resident perform part of activity, help of weight-bearing support was provided) with one person assist for transfers 20 out of 26 days. The ADL flow record revealed Resident #50 required total dependence (full staff performance of activity) with one person assist for transfer 1 out of 26 days. The ADL flow record revealed Resident #50 required supervision with transfer 4 out of 26 days. During an interview and observation on 4/25/22 at 10:15 a.m., Resident #50 was sitting in wheelchair visiting with a family member. He said he used to be able to walk with a walker but had to use a wheelchair now. Resident #50 said staff do not use a gait belt and one person assist when 675230 Page 9 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0689 transferring him. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/27/22 at 9:15 a.m., CNA J said she has worked at the facility for 7 years. She said her duties included bathing, showering, and feeding residents. CNA J said staff did not use a gait belt with Resident #50 transfer because he could bear weight and turn with one person assistance. Residents Affected - Few During an interview on 4/27/22 at 10:15 a.m., the ADON said she had been working at the facility since 1994. She said for a one person assist transfer they do not always use a gait belt. The ADON said if a resident was extensive assistance then a gait belt should be used. She said Resident #50 would need a gait belt and she would prefer two people to help transfer him. During an interview on 4/27/22 at 10:38 a.m., CNA G said she had worked at the facility for 5 years. She said her duties included making beds, take care of daily tasks, feeding residents, and providing ADLs assistance. CNA G said Resident #50 was a one person assist for transfers but had only worked with him once or twice. She said she uses a gait belt when transferring Resident #50. CNA G said using a gait belt during transfers protects you and the resident from harm. During an interview on 4/27/22 at 11:37 a.m., the DON said during a one person assisted transfer she expected staff to use good body mechanics and let the resident perform as much as possible to keep their independence. She said if a resident was a limited or standby transfer, then a gait belt may not be necessary. The DON said for an extensive assistance during transfer, a gait belt would be used. She said the computer system informed staff which type of assistance a resident required. The DON said therapy trained staff on how to properly transfer residents. During an interview on 4/27/22 at 1:28 p.m., the Rehab manager said one of her duties was to provide in-services for transfers to CNAs. She said she was doing in-services once a month to CNAs but since COVID she had not done any. The rehab manager said residents that required any type of assistance from supervision to total required a gait belt. She said using a gait belt helped the staff member protect their back and easier on the resident. The rehab manager all staff have been trained to use a gait belt except new CNAs. She said she had been laxed in providing in-services on transfers to new staff. The rehab manager said she did not know if CNAs were taught properly transfer skills in school. She said the facility used to do checkoffs on new hires to assess their skills, but no longer do that. The rehab manager said before COVID she tried to train the new CNAs on transfers the first couple of weeks from hire. She said Resident #50 required max assist and use of a gait belt was the minimum option to use for transfer. The rehab manager said if the CNA was small, she would recommend the use of a lift for Resident #50's transfer. She said she would not expect a CNA to transfer Resident #50 without a gait belt. The rehab manager said she did not know if CNAs received check offs thought out employment or if they were monitored by staff on proficiency. During an interview on 4/27/22 at 1:43 p.m., the Administrator said he expected staff to transfer a resident per their care plan. He said he would expect staff to follow the policy and procedures outlined for 1 or 2 persons assist for transfers. Record review of a facility ADL care-transfer techniques policy and procedure dated 2/12/20 revealed .staff will provide safe and effective transfer techniques for residents .review medical record, patient's order with range of motion limits and weight bearing status .use stand and pivot technique with one caregiver if appropriate .apply gait/transfer belt snugly and low .grasp transfer/gait belt keeping palm along resident's side . 675230 Page 10 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable and served at an appetizing temperature for 2 of 19 residents reviewed for palatable food. (Residents #16 and #62) Residents Affected - Few The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #16 and #62 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: 1. Record review of consolidated physician orders dated 4/27/2022 indicated Resident #16 was [AGE] years old and admitted on [DATE] with diagnoses to include diabetes, chronic obstructive pulmonary disorder (lung disease), and chronic atrial fibrillation (an irregular heart rhythm). Record review of the MDS dated [DATE] indicated Resident #16 was understood and understood others. A BIMS (Brief Interview for Mental Status) score of 15 indicated Resident #16 was cognitively intact. The MDS indicated Resident #16 required supervision to extensive assistance with ADLs. Record review of a care plan dated 2/16/22 indicated Resident #16 had impaired physical mobility and a self-care deficit. The care plan indicated the resident had altered nutrition status. 2. Record review of consolidated physician orders dated 4/27/2022 indicated Resident #62 was [AGE] years old and admitted on [DATE] with diagnoses to include diabetes, dementia, and chronic pain. Record review of the MDS dated [DATE] indicated Resident #62 was understood and understood others. A BIMS (Brief Interview for Mental Status) of 14 indicated Resident #61 was cognitively intact. The MDS indicated Resident #36 was independent with ADLs. Record review of a care plan dated 4/24/22 indicated Resident #62 was at risk for cognitive deficit related to diagnosis of dementia. The care plan indicated a BIMS score between 13-15 and was cognitively intact. The care plan indicated altered nutritional status due to being edentulous (lacking teeth). Record review of Resident #62's Weight Record indicated on 8/5/2019, Resident #62 weighed 204.9. On 4/4/2022, weighed 153.6. Record review of a lunch menu for 4/24/2022 revealed a lunch of orange glazed chicken, savory rice, broccoli florets, and a roll. There was a substitute of pork roast and gravy, potatoes, and confetti slaw. During an interview on 4/25/22 at 10:50 a.m., Resident #16 revealed the food is horrible. It is slop. They do not cook it right. Some of it is edible. Everything is cold. She said sandwiches were served every night. I've been getting stuff to make my own. She said she did not eat the beans and rice that were served on 4/24/22. She said the beans were cold and greasy. She said she was served a little pile of beans served with a little pile rice and cornbread. She said she told the aide, and the 675230 Page 11 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aide came back and told them there was no substitute. She said the food was bad every day and the food was very unattractive. During an interview on 4/25/22 at 10:51 a.m., Resident # 62 revealed she had lost close to 50 pounds since being admitted because she has been sick and doesn't like the food. She said she was told by an aide there was no substitute for lunch on 4/24/22 . She said she was hungry. She said all she had for lunch was an oatmeal cream pie and coffee. She said some of the food on the menu sounds good, but she never gets the food on the menu. She said their food did not appeal to her. She did not want the red beans and rice and was told there was no substitute. She said when hotdogs were served it just a bun and weenie and it was cold. She said because she did not have teeth, she cannot even chew a hotdog. During an observation on 4/26/22 at 12:55 p.m., the Dietician and three surveyors tasted a sample tray. The dietary supervisor said she did not want to sample the tray. The tray consisted of pork roast, brussel sprouts, sweet potato, cornbread, and banana cake. The pork roast was dry and the brussel sprouts were overcooked and mushy. During an interview on 4/26/22 at 2:35 p.m., Resident #62 revealed there was no bacon on her breakfast tray, and she cannot eat sausage. She said sausage was on her tray . She said, they know this. She said she did not like what they were having for the evening meal on 4/25/22 and she was provided a grilled cheese, but it was cold. She said they do not take pride in what they put out of that kitchen. I would be embarrassed. She said she had been told on several occasions that there was no more food and there was no substitute. She said she voiced complaints to the aides that bring her tray. During an interview on 4/26/22 at 03:01 p.m., Resident #16 revealed she had wanted milk at breakfast and was told they were out of milk. She said ate the black bean soup on 3/25/22 and it tasted terrible. She said she was told the egg sandwich also listed on the menu was considered the alternate. She was told she could only get one or the other. I guess if they do not fix enough, they don't have it to give out. She said she had complained to an aides about her food. During an interview on 4/26/22 at 2:48 p.m., CNA D revealed she said she had often heard food complaints especially from Resident #16 and #62. She said she reported complaints to the kitchen staff. She said the kitchen frequently did not have the substitute on the menu. She said the meals were usually not the same as what was listed on the menu. She said there was always a substitute, but it might not be what a resident wanted. During an interview on 4/26/22 03:10 p.m., LVN C revealed she had heard a few food complaints. She said most were that the residents were tired of eating the same things over and over. She said she reports resident complaints to the kitchen staff. During an interview on 4/27/22 at 9:00 a.m., [NAME] F revealed she had not heard a lot of food complaints. She said anytime food was sent back to the kitchen she always offered something else. She said there was always an alternate on the menu but sometimes they do change the menu and it could be something different. During an interview on 04/27/22 9:10 a.m., with the Dietary Supervisor revealed she had heard a few food complaints . She said anytime she gets a food complaint she goes and talks to the residents or family to make them aware of an alternate . She said, we can do anything they want within reason. She said she was unaware of staff telling residents there was no substitute for the day. She said she 675230 Page 12 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few this was not the kitchen staff. She said there were days when the residents had 2 or maybe 3 choices. She said peanut butter and jelly sandwiches were always available. She said the black bean soup and the egg salad was the main evening meal on 4/25/2022. She said the chef salad was the alternate. She said she was not sure who told the resident the resident could have one or the other. During an interview on 4/27/22 at 10:00 a.m., the ADON revealed she had heard food complaints. She said the complaints were usually because the residents did not want sandwiches in the evening. She said the residents were served sandwiches in the evening, but she could not say how often. She said there was always an alternate in the house. She said if someone complained, she would verbally notify the Dietary Supervisor of the complaint. During an interview on 04/27/22 at 10:24 a.m., CNA G revealed she does assist the residents with eating. She said she has heard a few food complaints from the residents. She said the residents told her they would like more food options. She said she reports any complaints to the kitchen staff. She said at times the kitchen does run out of items on the menu. She said she works 6-2 pm shift and had not seen sandwiches served . She said some residents had told her they were served sandwiches for supper on a regular basis. During an interview on 4/27/22 at 11:44 a.m., the DON said she had heard from certain residents that sandwiches were served too often for dinner. She said there were times the kitchen did not have exactly what was on the menu, but it was because food items were backordered due to be unavailable to the supplier. During an interview on 4/27/22 at 1:41 p.m., the Administrator revealed it was not acceptable for any staff member to go back to a resident and tell them they cannot have anything else out of the kitchen. He said he has 3 or 4 chronic complainers about the food. He said Resident #16 and Resident #62 complained often. He said he did go talk to them and tried to resolve the issue . He said there was always going to be something served that someone does not like to eat. He said there had been complaints of sandwiches being served too often in the evenings. He said the dietary manager was addressing the issue. He said he had been observing the lunch and dinner menu daily Monday through Friday to make sure it agrees with the menu and the ADON was checking when breakfast was served. A Food Palatability facility policy was requested on 4/27/2022 from the Dietary Supervisor and the Administrator and was not provided. 675230 Page 13 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

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 in 1 of 1 kitchen reviewed for food service safety. Residents Affected - Many The facility failed to ensure all food items were labeled and dated in the freezer and two refrigerators. The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. These failures could place residents at risk of foodborne illness. Findings included: Record review of a week 3 regular menu indicated for the evening meal on Monday black bean soup, egg salad sandwich, beet and onion salad, winter fruit cup, milk, iced tea and oil and vinegar dressing. The alternate was chef salad, garlic bread stick, salad dressing, milk whole, coffee, hot tea, hot chocolate and buttery spread. The breakfast menu for Tuesday morning indicated orange juice, oatmeal, French toast casserole, sausage patty, coffee, milk 1%, water, and syrup. The alternate breakfast menu indicated apple juice, cranberry juice, fruit loops, cheerios, cornflakes, raisin bran, cream of wheat, egg to order, bacon, sausage patty, Biscuit gravy, whole milk, hot tea, and jelly. Record review of a Refrigerator /Freezer Temperature Log dated April indicated Unit #3 (Refrigerator #2) on April 25 PM the refrigerator temperature was 55 degrees. The entry was initialed by the Dietary Supervisor. On April 26 AM the temperature for Unit #3 (Refrigerator #2) was 60 degrees. The entry was initialed by the Dietary Supervisor. During an observation on 4/25/22 at 9:18 a.m., revealed in the small chest type cooler in the kitchen there were two glasses with thick white liquid labeled BM with no date and 4 small round plastic to-go containers with lids with thick white substance sitting on a tray with no date or label. During an interview and observation on 4/25/22 at 9:12 a.m., revealed in refrigerator #1 in the pantry 2 clear plastic bags with yellow cornbread with no date or label. There was a plastic bag opened to air with an unknown cooked meat inside with no date or label. There was a metal container covered in foil labeled Red beans with no date. There was a metal container covered in foil with an unknown cooked green vegetable inside with no date or label. The dietary supervisor said the refrigerators were cleaned out twice a week. She said she checks the refrigerators on Mondays and throws out anything that does not have a date on it. She said there was a substitute cook working over the weekend and they may not have known to date or label the food. She said the full-time staff does know they were supposed to date and label food. During an observation on 4/25/22 at 9:27 a.m., revealed in refrigerator #2 inside the pantry a tray with beverages (4 glasses with a clear liquid, 2 glasses with an amber liquid, 1 glass with an orange liquid, and 1 glass with a red liquid), with no date or label. 675230 Page 14 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many There was 1 plastic zip bag with grated cheese, sliced cheese, and lunch meat inside with no date or label. There were cheese slices wrapped in plastic wrap with no date or label. There was a plastic zip bag with an unknown meat salad with no date or label. There was a tray with 25 small round plastic to-go contains with lids with a thick red substance in each sitting on a tray with no date or label. During an observation on 4/25/22 9:33 a.m., revealed in the freezer a plastic zip bag with brown frozen sticks of an unknown food item with no date or labels. There were 2 white bowls covered in plastic wrap with a frozen orange substance with no date or label. There were 3 pints of ice cream in a black plastic shopping bag with no date. There was a box labeled cheese pizza with 3 plastic bags of frozen unknown meat inside the box with no date or label. There was 1 gallon of Vanilla ice cream with no received date. There were 2 packages of unknown meat with no date of label. During an observation on 4/25/22 at 9:40 a.m., revealed 5 trays of glasses filled with an amber liquid and a clear liquid sitting next to the sink with no date or labels. During an interview and observation on 04/25/22 at 10:05 a.m., revealed refrigerator #1 the outside thermometer read 51 degrees and refrigerator #2 read 61 degrees . Refrigerator #1 contained a clear plastic bags with yellow cornbread with no date or label. There was a plastic bag opened to air with an unknown cooked meat inside with no date or label. There was a metal container covered in foil labeled Red beans with no date. There was a metal container covered in foil with an unknown cooked green vegetable inside with no date or label. , eggs, lettuce, and tomatos. Refrigerator #2 contained condiments, pickles, sliced cheese, grated cheese, lunchmeat pudding, an unknown fruit, an unknown green vegetable, 2 containers of sour cream, a box with 6 bags of sour cream and a container of cottage cheese. Both were checked with the thermometers on the outside of the refrigerators. [NAME] E said the refrigerators were not cooling like they should. She said fridge #1 had quit working 3 months ago and had to be worked on. She said she did not know when it had quit cooling again. She said it began leaking water on 4/24/22. The floor was wet near refrigerator #1. During an interview on 4/25/22 at 10:15 a.m., the Dietary Supervisor revealed the refrigerator temperatures were checked 3 times a day. She said the higher temperatures had not been reported to anyone because the temperature was normal when it had been checked earlier in the morning. She did not give a time the temperatures were checked. She said she had issues off and on with the refrigerators. She agreed both refrigerators were not cooling properly . She said the Maintenance Supervisor had been working on them and replaced a seal on refrigerator #1. During an observation on 4/25/22 at 11:25 a.m., the external thermometer on refrigerator #1 read the temperature at 52 degrees. The external thermometer on refrigerator #2 read 60.8 degrees. During an observation on 4/25/22 at 2:11 p.m., the external thermometer on refrigerator #1 read the temperature at 46 degrees. The external thermometer on refrigerator #2 read 59 degrees. During an interview on 4/25/22 at 2:13 p.m., the Maintenance Supervisor revealed there was a temperature log on all of the refrigerators. He said no one had reported to him any issues with refrigerators today. He said he had not seen a request for refrigerator repair in repair request logbook. During an observation on 4/25/22 at 2:15 p.m., revealed a black notebook at the nurse's station labeled for repair request from Maintenance. There was not a request for refrigerator repair. The last entry was 4/25/2022 for repair in the front bathroom. 675230 Page 15 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/25/22 at 02:16 p.m., the Dietary Supervisor revealed she had reported the issue with the refrigerators not cooling properly to the maintenance supervisor on the morning of 4/25/2022. She said she reported the issue to him when he came in her office this morning. She said she was working on removing the food. She said no food would be served out of the refrigerators and most of the evening meal would come out of the freezer. She said they were working on renting a refrigerator. Residents Affected - Many During an interview on 4/25/2022 at 3:45 p.m., the Maintenance Supervisor said the temperatures were too high in refrigerator #1 and refrigerator #2 when he had checked them. He said he had turned them both down and refrigerator #1 was now down to 45 degrees. During an observation on 04/26/22 at 8:20 a.m., Refrigerator #1 was at 45 degrees on a thermometer on the inside of the refrigerator and refrigerator #2 was at 59 degrees based on the external thermometer. Refrigerator #1 contained 1 full box of eggs and a partial box of eggs, lettuce, and tomato. Refrigerator #2 contained yellow mustard, ketchup, unknown fruit in a pitcher, 2 cartons of sour cream, 1 cottage cheese, pickles, 1 pudding, butter, unknown thick red substance with no label, jalapeno peppers, a box of broccoli, 2 bags containing chopped vegetables, and a box containing 6 bags of sour cream. During an interview on 4/26/2022 at 8:57 a.m., the Dietary Supervisor said the only thing served out of either of the refrigerators were the eggs used for egg salad sandwiches for dinner on 4/25/2022 and eggs were used for breakfast the morning the morning of 4/26/2022. During an interview on 04/27/22 at 09:00 a.m., [NAME] F revealed she was unaware of any cooling problems with the refrigerators. She said she does not check the temperatures on the refrigerators. She said the cook on the evening shift was the one that checks the temperatures. She said there was no log to record the refrigerator temperatures and if there was one she was not sure where it was kept. During an interview on 04/27/22 at 09:10 a.m., the Dietary Supervisor revealed on the morning of 4/25/2022 when she became aware of the high temperatures in the refrigerators, she mentioned it in passing to the maintenance supervisor. She said she could not find the repair request logbook. She said the process for reporting repair request was to tell the maintenance supervisor, the administrator and enter the request into a repair request logbook. She said no food was removed after she became aware of the issue and the eggs were still served for the evening meal and the next morning for breakfast. She agreed the refrigerators were at an unsafe temp for at least 4 hours on Monday. She said it was the cooks' job to check the refrigerator temperatures and put the temperatures on the log 3 times a day. She said the temperature log was kept in a notebook in the kitchen. She did not give an exact time for the temperatures to be recorded each day. She said if a food was stored at an unsafe temperature, it depends on what the food item was if it could possibly make residents sick or not. She said undated food could make residents sick because if it was undated you don't know how long it has been in the refrigerator. She said if any staff puts food in a refrigerator or freezer the food should be dated and labeled as it is being put in the fridge. She said she checks the refrigerators several times a week for undated and unlabeled food. She said anything undated or unlabeled is thrown away. She said she especially checks on Mondays for undated or unlabeled food because she had been off two days. During an interview on 4/27/22 at 01:41 PM, the Administrator revealed on 4/25/2022 the Dietary Supervisor came directly to him to notify him of the refrigerators not working properly. He said 675230 Page 16 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Corporate Maintenance was present. He said he immediately started making calls and had difficulty finding someone to come in to repair the refrigerators. He wanted someone to come in from directly from the outside to repair the refrigerator and not have the Maintenance Supervisor work on them. He said the facility has limited resources. He said he felt the eggs were still safe to eat. He said eggs can be at a certain temperature and still be ok. He said the Dietary Supervisor has documentation on this . He said when the Dietary Supervisor left at 7 pm on 4/25/2022, the temperature for refrigerator #1 was 40 degrees. On 4/27/2022 at 1:45 p.m., the egg safety documentation was requested from the Administrator and was not received prior to exit. Review of a facility Hot and Cold Food Temperatures policy dated August 1, 2008 indicated, .The temperatures of the food items will be managed to conserve maximum nutritive value and flavor and to be free of harmful organisms and substances . Review of a facility Food Storage policy dated August 1, 2018 indicated, .Sufficient storage facilities are provided to keep foods safe .food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .Refrigerator: .temperatures are at or below 40 degrees Fahrenheit .all foods are covered, labeled, and dated .Freezer: .all foods are covered, labeled, and dated . Review of an article published by the Food and Drug Administration What you need to know about egg safety, https://www.fda.gov/food/buy-store-serve-safe-food/what-you-need-know-about-egg-safety, dated March 2021 indicated, .Fresh eggs, even those with clean, uncracked shells, may contain bacteria called Salmonella that can cause foodborne illness, often called food poisoning .Certain people are at greater risk for severe illness and include children, older adults .Safe Handling Instructions to prevent illness from bacteria: keep eggs refrigerated .store promptly in a clean refrigerator at a temperature of 40 degrees F or below . 675230 Page 17 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

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 maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. Residents Affected - Many The facility failed to ensure Refrigerator #1 and Refrigerator #2 maintained a safe storage temperature. This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness. Findings included: Record review of a Refrigerator /Freezer Temperature Log dated April indicated Unit #3 (Refrigerator #2) on April 25 PM the refrigerator temperature was 55 degrees. The entry was initialed by the Dietary Supervisor. On April 26 AM the temperature for Unit #3 (Refrigerator #2) was 60 degrees. The entry was initialed by the Dietary Supervisor. During an interview and observation on 04/25/22 at 10:05 a.m., revealed refrigerator #1 the outside thermometer read 51 degrees and refrigerator #2 read 61 degrees. Both were checked with the thermometers on the outside of the refrigerators. [NAME] E said the refrigerators were not cooling like they should. She said fridge #1 had quit working 3 months ago and had to be worked on. She said she did not know when it had quit cooling again. She said it began leaking water on 4/24/22. The floor was wet near refrigerator #1. During an interview on 4/25/22 at 10:15 a.m., the Dietary Supervisor revealed the refrigerator temperatures were checked 3 times a day. She said the higher temperatures had not been reported to anyone because the temperature was normal when it had been checked earlier in the morning. She did not give a time the temperatures were checked. She said she had issues off and on with the refrigerators. She agreed both refrigerators were not cooling properly. She said the Maintenance Supervisor had been working on them and had replaced a seal on refrigerator #1. During an observation on 4/25/22 at 11:25 a.m., the external thermometer on refrigerator #1 read the temperature at 52 degrees. The external thermometer on refrigerator #2 read 60.8 degrees. During an observation on 4/25/22 at 2:11 p.m., the external thermometer on refrigerator #1 read the temperature at 46 degrees. The external thermometer on refrigerator #2 read 59 degrees. During an interview on 4/25/22 at 2:13 p.m., the Maintenance Supervisor revealed there was a temperature log on all of the refrigerators. He said no one had reported to him any issues with refrigerators today. He said he had not seen a request for refrigerator repair in repair request logbook. During an observation on 4/25/22 at 2:15 p.m., revealed a black notebook at the nurse's station labeled for repair request from Maintenance. There was not a request for refrigerator repair. The last entry was 4/25/2022 for repair in the front bathroom. During an interview on 04/25/22 at 02:16 p.m., the Dietary Supervisor revealed she had reported the issue with the refrigerators not cooling properly to the maintenance supervisor on the morning of 675230 Page 18 of 19 675230 04/27/2022 Pine Grove Nursing Center 246 Haley Dr Center, TX 75935

F 0908 4/25/2022. She said she reported the issue to him when he came in her office that morning. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/25/2022 at 3:45 p.m., the Maintenance Supervisor said the temperatures were too high in refrigerator #1 and refrigerator #2 when he had checked them. He said he had turned them both down and refrigerator #1 was now down to 45 degrees. Residents Affected - Many During an observation on 04/26/22 at 8:20 a.m., Refrigerator #1 was at 45 degrees on a thermometer on the inside of the refrigerator and refrigerator #2 was at 59 degrees based on the external thermometer. Refrigerator #1 contained 1 full box of eggs and a partial box of eggs, lettuce, and tomato. Refrigerator #2 contained yellow mustard, ketchup, unknown fruit in a pitcher, 2 cartons of sour cream, 1 cottage cheese, pickles, 1 pudding, butter, unknown thick red substance with no label, jalapeno peppers, a box of broccoli, 2 bags containing chopped vegetables, and a box containing 6 bags of sour cream. During an interview on 04/27/22 at 09:00 a.m., [NAME] F revealed she was unaware of any cooling problems with the refrigerators. She said she does not check the temperatures on the refrigerators. She said the cook on the evening shift was the one that checks the temperatures. She said there was no log to record the refrigerator temperatures and if there was one she is not sure where it was kept. During an interview on 04/27/22 at 09:10 a.m., the Dietary Supervisor revealed on the morning of 4/25/2022 when she became aware of the high temperatures in the refrigerators, she mentioned it in passing to the maintenance supervisor. She said she could not find the repair request logbook. She said the process for reporting repair request was to tell the maintenance supervisor, the administrator and enter the request into a repair request logbook. She said no food was removed after she became aware of the issue and the eggs were still served for the evening meal and the next morning for breakfast. She agreed the refrigerators were at an unsafe temp for at least 4 hours on Monday. She said it was the cooks' job to check the refrigerator temperatures and put the temperatures on the log 3 times a day. She said the temperature log was kept in a notebook in the kitchen . She did not give an exact time for the temperatures to be recorded each day. She said if a food was stored at an unsafe temperature, it depends on what the food item is if it could possibly make residents sick or not. During an interview on 4/27/22 at 01:41 PM, the Administrator revealed on 4/25/2022 the Dietary Supervisor came directly to him to notify him of the refrigerators not working properly . He said Corporate Maintenance was present. He said he immediately started making calls and had difficulty finding someone to come in to repair the refrigerators. He wanted someone to come in from directly from the outside to repair the refrigerator and not have the Maintenance Supervisor work on them. He said the facility has limited resources. He said he felt the eggs were still safe to eat. He said eggs can be at a certain temperature and still be ok. He said the Dietary Supervisor has documentation on this. He said when the Dietary Supervisor left at 7 pm on 4/25/2022, the temperature for refrigerator #1 was 40 degrees. The Administrator said the only policy available was concerning the dish washer and the ice machine. He said there was no policy available for the refrigerators. On 4/27/2022 at 1:45 p.m., a refrigerator policy was requested from the Dietary Supervisor and the Administrator on 4/27/2022. The Administrator said there was not one available. 675230 Page 19 of 19