Inspection·August 7, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete enough for the residents to see. The menu is written on the chalkboard in the kitchen before the meal is served in the dining room.Record review of Menus and Adequate Nutrition Policy, revised on 7/16/2025, reflected Policy.Menus will be followed as posted. Notification of any deviations from the menu shall be made as soon as practicable. Substitution shall comprise of foods with comparable nutritive value.Menus shall be prepared at least two weeks in advance for timely approval and ordering of food. Menus will be posted in the kitchen and in areas accessible by residents at least one week in advance.Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking. Review of the federal food code. Federal food safety regulations for nursing homes are primarily outlined in 42 CFR S 483.60, which addresses food and nutrition services. These regulations emphasize providing residents with a nourishing, palatable, and well-balanced diet that meets their individual nutritional needs and preferences. Key aspects include ensuring food safety, proper staffing, and adherence to dietary requirements. Event ID: Facility ID: 675406 If continuation sheet Page 2 of 4 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 675406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661 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 - Some 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 in 1 of 1 kitchen reviewed for Food and Nutrition Services. 1. The facility failed to ensure that expired foods were discarded. 2. The facility failed to ensure the food processor was sanitized between each food item. 3. The facility failed to ensure food items were labeled and dated. 4. The facility failed to ensure that serving utensils and dishes were not stored dirty.These failures could place residents at risk for foodborne illness, causing the residents to get sick in 1 of 1 kitchen. Findings included: Observation on 8/05/2025 at 7:30 AM of the walk-in refrigerator reflected the following:- Tomatoes in a sealed bag were dated 7-22 with no discard date. - Strawberries in a container had no date and were moldy. - A cardboard box, dated 7-02-2025, contained green grapes were brown. - Sliced cheese in a Ziplock bag, dated 8-01-25, had no discard date. - Celery in a sealed bag, dated 8-02-25 had no discard date. - Asparagus in a Ziplock bag, dated 8-01-25, had no discard date.Observation on 8/05/2025 at 7:40 AM of the kitchen reflected the following:- Blue coffee cups on a dishwasher rack with other clean items had white debris on the cups. - Utensils in a dishwasher rack were mixed with clean and dirty utensils. - Serving utensils stored in a clear container had food debris in with the serving utensils. Observation on 8/05/2025 at 11:04 AM of the kitchen reflected the following:CK A Pureed the green beans, then rinsed the food processor in hot water without sanitizing the food processor. There were still pureed green beans inside the food processor when CK A pureed baked beans. CK A then rinsed the blender in hot water, but it was not sanitized before pureeing the bread. CK A then Pureed the cabbage without sanitizing the food processor. CK A rinsed the blender in hot water and did not sanitize the food processor before pureeing the ham.Observation on 8/06/2025 at 11:15 AM of the kitchen reflected the following:CK A pureed the chicken, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the green beans, then rinsed the food processor in hot water without sanitizing it for the next food item. CK A pureed the potatoes. An interview on 8/07/2025 at 10:20 AM with CK B CK B stated when he put a food item in a container, he added the date on the container. CK B stated he checked daily for expired food items. If he saw an expired food item, he then threw it away. CK B stated any prepared food items past 3 days were thrown away. CK2 said there was no list they went by that told him how many days an item could be stored before it was thrown away. CK B stated prepared food was stored for three days before being discarded. CK B stated the kitchen was cleaned daily. CK B said there was a cleaning checklist they used. CK B said he was supposed to clean and sanitize the food processor in between food items. CK B said he forgot to do it this time. CK B said he was supposed to change his gloves when he did something else and came back to pureeing food. CK B said it had been a while since there was any training. CK B stated a resident could get sick if the equipment was not thoroughly cleaned and he did not change his gloves.An interview on 8/07/2025 at 10:29 AM with the DA revealed when the truck arrived, all staff are responsible to make sure that food items are dated. When a prepared item was placed in a Ziplock bag, it should have the date it was stored and an expiration date. If she noticed food going bad, she informed the DM and disposed of it. The DA mentioned everyone checked the walk-in cooler for expired items. The DA said staff did not put the expiration date on the packages. The DA stated prepared items should be discarded after three days because then the item is not good. The DA said the kitchen was cleaned daily at the end of each shift, including sweeping and mopping. DA said that residents could get sick if hand hygiene was not followed.An interview on 8/07/2025 at 10:20 AM with the DM revealed they went by newest item in the back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675406 If continuation sheet Page 3 of 4 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 675406 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Years Nursing and Rehabilitation Center 318 Chambers St Marlin, TX 76661 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and the oldest in the front. The DM said items were checked daily to see if there were any expired food. If there was expired food in the cooler it should be thrown away. The DM said food should be labeled with the name of the item, the date it was added, as well as the expiration date. The DM stated there was a list that had the shelf life of different foods. The kitchen was cleaned and sanitized daily. There were policies for sanitation, hand hygiene and food storage. The DM stated if equipment and utensils were not sanitized or cleaned, then it could be an infection control issue. An interview on 8/07/2025 at 10:20 AM with the ADM revealed when a food item was prepared and stored in a Ziplock bag, it should have the date it was put in the bag and the expiration date. The DM said when there was an out-of-date item, it should be thrown out. Looking for items should be checked weekly by staff. The kitchen should be cleaned and sanitized daily. There were polices in place for out-of-date food and the food should be discarded, and Kitchen equipment should be sanitized. The expectations are for staff to check for out-of-date food items and sanitized equipment. The ADM stated if out-of-date food was served to the residents, they could get sick. The ADM stated if equipment and utensils were not sanitized or cleaned, and said that CK A and CK B said they forgot to sanitize the equipment. then it could be an infection control issue.Record review of the facility's Sanitation policy, updated October 2008, reflected Policy Interpretation and Implementation: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions.4. Sanitizing of environmental surfaces must be performed with one of the following solutions:a. 50-100 ppm chlorine solution.b. 150-200 ppm quaternary ammonium compound (QAC); orc. 12.5 ppm iodine solution.5. Sanitizing of utensils and removable parts of equipment should be accomplished in one of the following ways:a. Contact for at least 30 seconds with an iodine solution (at approved concentration);b. Contact with QAC (at approved concentration) per manufacturer's instructions.c. Contact for at least l 0 seconds with a chlorine (at approved concentration); ord. Immersion for thirty (30) seconds in hot (at least 171 F) water.Record Review of the facility's, undated, Food Storage Policy reflected: All foods shall be dated with the month and year received and shall be rotated on the first in/first out basis upon receipt. The oldest items are to be moved to the front to be used first. Food shall be purchased in quantities which can be stored properly. Frozen products purchased in larger quantities than needed are divided into appropriate quantities, wrapped, and labeled with the description of the product, the date it was wrapped and placed in the freezer. Event ID: Facility ID: 675406 If continuation sheet Page 4 of 4