Health inspection·May 5, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 service safety for one of one kitchen reviewed for kitchen sanitiation in that: 1. Cook A failed to sanitize the temperature gauge after each use. This failure could place residents at risk for food contamination and/or food-borne illness. Findings included: During a kitchen observation on 05/05/23 at 5:24 PM, [NAME] A was observed taking the temperature of food with a temperature gauge. [NAME] A was observed as he walked to the sink area and pulled a couple of paper towels from the dispenser. [NAME] A checked the temperature of the shredded beef with the temperature gauge, then wiped the temperature gauge with a dry paper towel before checking the temperature of the potato wedges. [NAME] A used the same dry paper towel and wiped the temperature gauge again before checking the temperature of the mixed vegetables. [NAME] A was observed as he dropped the paper towel on the floor. He was then observed going back to the paper towel dispenser to get more paper towels to finish checking temperatures. [NAME] A was observed as he checked the temperatures of the pureed food items, in which he also used the dry paper towel to wipe off the temperature gauge after each pureed food item. [NAME] A did not sanitize the temperature gauge between each use. In an interview on 05/05/23 at 7:12 PM, [NAME] A stated that he usually checked the temperatures of the food, but sometimes he did forget. [NAME] A stated kitchen staff should clean the temperature gauge after each use. He stated that he knew to wipe the temperature gauge. He stated that he could not locate the alcohol wipes. [NAME] A stated he used the paper towels, because he could not locate the alcohol wipes. He stated that he knew a risk would have been food contamination. In a telephone interview on 05/05/23 at 7:20 PM, Dietary Supervisor stated she spoke with [NAME] A, and [NAME] A told her he forgot the cup of cleaner and the alcohol wipes. She stated he had been trained on how to properly clean the temperature gauge, which was to clean it with alcohol wipes after each use. Dietary Supervisor stated that one risk of not sanitizing the temperature gauge after each use was cross contamination. In an interview on 05/05/23 at 7:35 PM, Administrator stated she was aware of the temperature gauge (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: 675305 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 675305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Valley Healthcare and Rehabilitation Cent 1525 Pleasant Valley Rd Garland, TX 75040 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)