Health inspection·October 4, 2024

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements: The DS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 10/1/24 at 2:10 p.m., the DS stated she was in training, was not certified and had registered for the CDM course two weeks ago but had been too busy in the kitchen working as the cook, dietary aide, washing dishes and being the supervisor. The DS stated she did not have an associate's or higher degree in food service management and had not been a dietary manager in a long-term care facility. The DS stated she worked in the facility previously as the cook. During a follow up interview on 10/2/24 at 7:50 a.m., the DS stated she was offered the position of DM late August of 2024 and further stated, as of today I am not actually taking the course for CDM. During an interview on 10/3/24 at 1:34 p.m., the Administrator stated the DM, or the DS had to have certain credentials to be the DM and stated the facility did not have a DM. The Administrator stated she had only been the administrator in the facility for just over a week and was aware the facility did not have a DM and was working on the DS getting certified. During a telephone interview on 10/4/24 at 9:51 a.m., the RD stated he came to the facility once a month and had last visited in September 2024. The RD stated he believed the DM was the DS, and she was in control of the meal prep. The RD stated he provided the sanitation report, dining, and the kitchen observation but was not involved in the DS's training or involved in any DM active duties. During an interview on 10/4/24 at 11:01 a.m., the BOM stated she was responsible for hiring and background checks on potential employee new hires. The BOM stated the DS was hired by the facility as a dietary aide on 8/9/24 and assumed the position of DS shortly after that. The BOM stated, the DS did not have the credentials to be considered DM and had not even started the training courses. The Page 1 of 6 675532 675532 10/04/2024 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some BOM stated, when the DM left, the owner of the facility had conversations with the DS about getting her certification but the problems with turnover in the kitchen did not give her any time to get the certification. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12. 675532 Page 2 of 6 675532 10/04/2024 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal reviewed for food and nutrition services in that: The facility failed to ensure Resident #1 received a health shake with his lunch meal on 10/3/24. This failure could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 10/3/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included acute gastritis (sudden inflammation or swelling of the stomach lining causing acid to irritate and inflame the lining) with bleeding, esophageal obstruction (blockage or narrowing of the esophagus, the tube that carries food and liquids from the mouth to the stomach), heartburn (burning sensation or discomfort in the chest or throat often caused by acid reflux), gastro-esophageal reflux disease (backward flow of stomach acid or contents into the esophagus), abnormal weight loss, and protein-calorie malnutrition (condition caused by a deficiency of both protein and calories in the diet leading to a range of health issues). Record review of Resident #1's most recent annual MDS assessment, dated 7/30/24 revealed the resident was moderately cognitively intact for daily decision-making skills, was diagnosed with malnutrition and received a mechanically altered diet texture. Record review of Resident #1's Physician Order Report, dated 8/1/24 to 10/3/24 revealed the following: -Diet: LCS/Pureed diet/Thin liquids, Special Instructions: HOUSE SHAKES WITH MEALS [DX: Esophageal obstruction] Three Times A Day; 0800 AM, 12:00 PM, 05:00 PM, with order date 8/6/24 and no stop date Record review of Resident #1's comprehensive care plan, with review date 8/27/24 revealed the resident was on a planned weight gain program related to history of significant weight loss and low BMI, with approaches that included to Provide supplements: house shakes with meals and TID. During an observation on 10/3/24 at 11:32 a.m., during the lunch meal, revealed the [NAME] and Dietary Aide C preparing the lunch trays. Dietary Aide C was overheard saying, we just got the shakes delivered this morning, but won't get to serve them at lunch because they are still frozen. During an interview on 10/3/24 at 11:58 a.m., Dietary Aide C revealed, Resident #1 would be getting two cartons of milk and a serving of apple sauce instead of the milk shakes he was supposed to get because they ran out of milk shakes last night. Dietary Aide C further stated the shipment of milk shakes were delivered to the facility earlier that morning but would not be served because they were frozen. During an observation and interview on 10/3/24 at 12:15 p.m., revealed Resident #1 sitting up in 675532 Page 3 of 6 675532 10/04/2024 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0803 Level of Harm - Minimal harm or potential for actual harm bed eating his lunch and there were no milk shakes on the tray. Resident #1's meal ticket revealed he received a regular, pureed diet and supplements that included 1 carton of vanilla milk shake, and a note that stated, HOUSE SHAKE WITH EVERY MEAL. Further review of the meal ticket revealed 2 milk was handwritten with a black marker. Resident #1 stated he did not get a house shake, they ain't got none. The last time I got a shake maybe day before last. They're out of shakes and I get 2 with every meal. Residents Affected - Few During an interview on 10/3/24 at 12:43 p.m., the DS stated Resident #1 always asked for 2 milk shakes and 2 milks. The DS stated, We can give him an extra milk and at dinner he will be served his house shake. The DS stated the facility received a delivery earlier that morning that included the house shakes but because they were delivered frozen, they were not served to the resident at lunch, but he will get it at dinner because it should be thawed by then. The DS stated the facility ran out of house shakes the night before and was not served during dinner. During an interview on 10/3/24 at 1:31 p.m., LVN D revealed she had checked Resident #1's lunch tray and was aware the resident was supposed to receive a house shake with meals, but confirmed the resident received a carton of milk instead. LVN D stated since the resident did not have a milk shake on the lunch tray when she checked it, she assumed the kitchen didn't have any, so I didn't ask them. LVN D stated, I wouldn't call the doctor about getting a substitution for the milk shake, that would be up to the kitchen staff. During an interview on 10/3/24 at 1:45 p.m., the DON revealed Resident #1 had a physician's order for a house shake with every meal. The DON further stated the kitchen staff could offer an alternative, but it was ultimately up to the physician to order a substitute if the resident did not receive it because it was not available, then the doctor should have been notified. Record review of the facility policy and procedure titled, Food Preparation and Food Service, undated, revealed in part, .The primary purpose of the dietary department of this facility is to prepare and serve meals in a way to ensure that the food and nutrition service is operating in a safe, sanitary and efficient matter. The menus are prepared in accordance with the physician's orders and to meet the Recommended Dietary Allowance of the Food and Nutrition Board, National Research Council . 675532 Page 4 of 6 675532 10/04/2024 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

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 for food service safety for 1 of 1 kitchen: Residents Affected - Some 1. The facility failed to store, label and date food items properly in 3 of 3 reach in freezers. 2. The DS, Cook, and Dietary Aide C were not wearing hair restraints properly during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation and interview with the DS on 10/1/24 at 11:09 a.m. revealed the following: -Reach in Freezer #1 contained 6, gallon size bags of frozen biscuits with no date indicating a use by date. The DS stated they had just received the shipment early in the morning, maybe between 5:30 a.m. and 6:00 a.m. and should have been labeled prior to being placed in the freezer. The DS stated the dietary staff were responsible for labeling the items and the label should identify when the item was received and the date it should be discarded. -Reach in Freezer #2 a gallon bag of a frozen food item that could not be identified with no date indicating a use by date. -The temperature logs for reach in Freezer #1 and reach in Freezer #2 was missing documentation of the temperatures on 9/28, 9/29, 9/30, and 10/1. -A large, opened box of jars of jelly were on the floor between reach in Freezer #1 and reach in Freezer #2. The DS stated the box of jelly should not have been on the floor because it was considered cross contamination. -Reach in Freezer #3 had one medium metal container with cooked beans loosely covered in foil with no date indicating a use by date. One large metal container was observed with cooking oil with food particles that appeared to be old cooking oil was loosely covered in foil with no date indicating a use by date. The DS stated, I don't know why anybody would put that in the refrigerator. One large zip lock bag was observed with 4 frozen Salisbury steaks, with expiration date 9/15/24. One large zip lock bag with frozen bacon was observed with expiration date 9/18/24. 2. Observation on 10/1/24 at 12:19 p.m. revealed the [NAME] in the kitchen, leaning on the stove, wearing a baseball cap and his goatee which was approximately ¼ inch in length, was not properly restrained. During an interview on 10/1/24 at 12:25 p.m., the [NAME] stated he realized he was not wearing a hair restraint or a beard cover because he had forgotten. The [NAME] stated he was supposed to wear a hair restraint in case hair falls into the food. 675532 Page 5 of 6 675532 10/04/2024 Uvalde Healthcare and Rehabilitation Center 535 N Park St Uvalde, TX 78801

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation during the lunch service on 10/3/24 at 11:32 a.m., revealed the [NAME] was not wearing a beard cover while preparing the lunch trays. Further observation revealed the DS was next to the steam table with the [NAME] and her hair, made up in a braid, was not tucked into the hair restraint. The DS's braid was approximately 3 inches in length. DA C was observed taking the assembled trays from the [NAME] and placed beverages and utensils on the trays. DA C's hair restraint did not cover her head entirely and was observed with approximately ¼ hair protruding from her temples and behind her neck. During an interview on 10/3/24 at 12:38 p.m., DA C stated she was not aware she had hair sticking out of the hair restraint and stated any hair sticking out of the restraint could end up in the food. During an interview on 10/3/24 at 12:43 p.m., the DS stated, she was not aware her hair was not fully tucked and covered by the hair restraint. The DS stated it was not supposed to be that way because hair could fall into the food and it was considered cross contamination. Record review of the facility policy and procedure titled, Employee Information, undated, revealed in part, .Hair nets or hair restraints must be worn at all times in the kitchen. All hair must be under the hair net. Employees with facial hair must wear beard guards or hair nets to restrain the facial hair at all times in the kitchen . Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. 675532 Page 6 of 6