Inspection·March 7, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shift on 03-05-24 at 6:00 a.m. She stated that Resident #12 was total care as such, he was her first stop when beginning her shift. She stated when she entered the resident's room, she saw the call bell cord hanging on the gallon of water sitting on the resident's nightstand. She stated she changed the resident's brief and gowned and meant to attach the call bell to the resident's pillow before leaving the room but had forgotten. She stated that she had fed resident breakfast and lunch on 03-05-24. She apologized and stated that the importance of call bells in place was so that residents who needed assistance would be able to reach staff. Interview on 03-06-24 at 03:57 p.m., LVN C stated that when she entered Resident #12's room on 03-25-24 at 12:03 p.m. she had not even realized that the resident's call bell was hanging on the gallon of water sitting on his nightstand. She stated that she had not seen it hanging like that before and would be certain to notice the call lights placement in the future. She stated that the importance of resident's call light in reach was for residents' ability to call for patient care and assistance. Interview on 03-07-24 at 02:59 p.m., DON stated that Resident #12 was total care and based on the resident's diagnosis he had required frequent checks. She stated that resident call lights should be in place/and in reach at all times for residents to reach staff when needed. She stated that the facility would be replacing Resident #12's call bell with a call pad that would attach to the resident's bed and would allow him to roll on the pad to call staff rather than having to push the call bell with his hands. She stated that that nursing staff were in-serviced on call bell placement on 03-06-24. Interview on 03-07-24 at 03:31 p.m., Administrator stated that CNA A informed her of Resident #12's call bell positioning. She stated that staff need to slow down and not get too focused on the tasks that they forget to ensure that resident's call bells were in place. She stated that they would be implementing a call bell pad that would be placed on Resident #12's bed. She stated the call bell pad would allow the resident to roll his shoulder on the pad rather having had to push a call bell button to call for staff assistance. She stated the importance of the call bell system to be in reach was for residents to call for staff assistance. She stated that the nursing staff were in-serviced, and she would provide a copy. Record Review of policy Answering Call Lights revised date September 2022 revealed that, Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. The facility provided in-services on Ensuring call lights in reach for residents conducted by ADON on 03-06-24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 2 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 one resident (Resident #147) of five residents reviewed for oxygen therapy was provided care that was consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Residents Affected - Few -Resident #147 had an oxygen humidifier that was dated 02/19/2024, 10 days prior to his admission on [DATE], and possibly previously used by a different resident. Resident #147 had been recently admitted to the facility with respiratory compromise. The failure placed Residents at increased risk of infection. Findings included: Record review of the admission Record (printed 03/05/2024) revealed Resident #147 was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, and other mental changes), pleural effusion (buildup of fluids around the lungs), and anoxic brain damage (brain damage caused by lack of oxygen). Record review revealed Resident #147 had been in the facility for less than five days and did not yet have a MDS assessment. Record review of a Physician's Order dated 03/04/2024 at 9:31 p.m. revealed, in part, .Administer O2 2L via NC if Patient desaturates below 90%. Record review of a Health Status Note dated 03/04/2024 at 10:00 p.m. revealed the Nurse Practitioner gave orders for Augmentin 875-125 mg (antibiotic) to be given orally twice daily for seven days, Ceftriaxone 2 gm (antibiotic) to be administered via intra-muscular injection daily for three days, metronidazole 500 mg (antibiotic) to be given orally every eight hours for seven days, and Guaifenesin 100mg/5 ml - 300 mg (expectorant) to be given every six hours for ten days. In addition, the resident was to receive Duoneb nebulizer treatments every six hours for seven days. The Note also reflected Resident #147 was to receive oxygen PRN (as needed) at 2L. There was a standing order to send the resident to the hospital if his oxygen saturation level was below 90%. The note reflected the MAR was updated with the orders. The Note was signed by LVN A. Record review of the Orders Administration Note dated 03/04/2024 at 10:27 p.m. revealed the diagnosis as Pneumonia. Record review of Resident #147's Care Plan on 03/05/2024 at 10:00 a.m. revealed it did not yet address the Pneumonia diagnosis from 03/04/2024 at 10:27 p.m. Observation on 03/05/2024 at 9:35 a.m. revealed Resident #147 was lying in bed, awake. He responded to a verbal greeting by nodding, but he was non-verbal. There was an oxygen concentrator with a humidifier reservoir. The concentrator was set at 3L, delivering oxygen to the resident via nasal cannula. The humidifier was a refillable type. The date scribed on the top of the humidifier was 02/19/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 3 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation and interview on 03/05/2024 at 9:37 a.m. revealed the surveyor asked Resident #147's Charge Nurse, LVN B, to check the oxygen humidifier for Resident #147. LVN B looked at the humidifier and confirmed the date was 02/19/2024. She said the resident was admitted yesterday (03/04/2024), and that the humidifier should be changed every week. Observation and interview on 03/05/2024 at 11:40 a.m. the DON said humidifiers were to be changed out weekly. The DON observed the humidifier being used for Resident #147 and confirmed the date was 02/19/24. The DON said humidifiers were available in the storage room, and the nurses had access to the storage room. Observation and interview on 03/05/2024 at 11:43 a.m. revealed a storage room on Hall E. The DON opened the door with a key. There were no oxygen concentrators or humidifiers in the room. The DON said if the nurses could not find any humidifiers in the room, they should have called her. She said the facility now uses pre-filled (non-refillable) humidifiers, but the one in Resident #147's room was the refillable type. The DON said she did not know if it was facility policy to reuse refillable humidifiers for different residents, but she would check the policy. She said the risk of reusing refillable humidifiers would be increased risk of infection. At that time the DON attempted unsuccessfully to call LVN C, the 10:00 p.m. (03/04/2024) to 6:00 a.m. (03/05/2024) charge nurse for Resident #147. In an interview on 03/05/2024 at 11:53 a.m. the DON said the facility policy was to not reuse humidifiers. Observation on 03/05/2024 at 12:02 p.m. revealed the oxygen tubing and humidifier for Resident #147 had been changed. The humidifier was the non-refillable type. The scribed date was 03/05/2024. In an interview via on 03/05/2024 at 12:03 p.m. LVN B said she had just changed the humidifier for Resident #147. She said the facility was not to reuse humidifiers because it would be a risk for infection. In an interview via telephone on 03/06/2024 at 5:00 a.m. RN C confirmed she was Resident #147's Charge Nurse for the night shift on 03/04/2024. She said the evening nurse (LVN A) had received the order and was entering them into the computer when she arrived. RN C said the oxygen concentrator was already in Resident #147's room when she initially entered the room that night. She said the refillable humidifier was on the concentrator, but it was empty. She said she had a pre-filled humidifier, but it was too big to fit on that concentrator. She said she opened the pre-filled humidifier and emptied the contents into the refillable humidifier. She said she thought the refillable humidifier was new, so she just filled it. In an interview via telephone on 03/06/2024 at 3:25 p.m. LVN A said she had received the order for the oxygen on 03/04/2024 at around 9:30 p.m. to 10:00 p.m. Change of shift was at 10:00 p.m. She said she entered the order, then got the concentrator. She said she saw that it had the old refillable humidifier on it. She said she started the concentrator and asked RN C to put on a new humidifier. LVN A said before the oxygen order, an x-ray report revealed Resident #147 had pneumonia. Record review of the facility policy entitled Oxygen Administration (revised October 2010) revealed a humidifier was to be used but did not reflect new. The policy reflected, in part, .12. Check the mask, tank, humidifying jar, etc. to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 4 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 0695 water bubbles as the oxygen flows. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 5 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with established food preparation practices and safety techniques in that; Residents Affected - Few 1. Frozen food were thawed in a sink with no running and/or standing water. 2. Frozen food were thawed in a sink used for hand washing. This failure could cause food-borne illnesses as a result and could affect the residents who consumed food from the facility's only kitchen. Findings included: Observation of the kitchen on 03-05-24 at 08:47 a.m., revealed 2 of 2 sinks used for hand washing. Observation of the kitchen on 03-05-24 at 11:52 a.m. 3-10 pound loafs of sealed frozen ground beef in 1 of 2 sinks used for hand washing without being submerged in standing water or under running cold water. Observation of the lunch meal tray on 03-06-24 at 12:55 p.m., revealed a regular textured meal consisting of meat loaf, green beans, dinner roll, mashed potatoes and gravy, and pudding. The meal was visually presentable and was tasted and found palatable. Interview on 03-05-24 at 08:47 a.m., [NAME] A stated that there were 2 of 2 sinks used for hand washing. She stated one near the stove and one near the dish machine and either could be used by Surveyor A to wash hands. Interview on 03-05-24 at 11:52 a.m., [NAME] A stated the ground beef loafs in the sink near the stove were being thawed for tomorrow's lunch. Interview on 03-06-24 at 08:40 a.m., [NAME] A when asked was that meat she was seasoning had been the same meat observed in the sink thawing 03-05-24, [NAME] A stated, The meat was thawed and stored in the refrigerator overnight. Interview on 03-06-24 at 1:10 p.m., [NAME] B stated that she used the handwashing station located near the dish machine. She stated on 03-05-24 the frozen ground beef loafs were placed in the sink near the stove by who she believe to be [NAME] A on the first shift to thaw. She stated later that afternoon, she placed the meat loafs in a pan and placed them into the refrigerator until the next day when they would be cooked for lunch. She stated the process for thawing food consisted of removing the frozen food item from the freezer, the item would be placed in a pan into the sink near the stove, and then cold water was to be ran over the item until thawed. She stated that the frozen food should be placed in a pan to avoid contaminating the sink and avoid any contamination from the sink onto (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 6 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 the food. Level of Harm - Minimal harm or potential for actual harm Interview on 03-06-24 at 01:23 p.m., Dishwasher stated that he was responsible for washing dishes, but while he does not cook any food, he did handle food items such as pudding, cereal, coffee, and bread to plate trays. He stated that he was instructed upon hire to only use the handwashing sink near the dish machine. He stated he did not know why he could not use the hand washing sink near the stove. He stated he did not defrost food items in the kitchen and was not aware who thawed the ground beef loafs in the sink on 03-05-24. Residents Affected - Few Interview on 03-06-24 at 01:40 p.m., Tray Aid stated she had been responsible for assisting the cooks plate trays and making sandwiches. She stated that she was instructed to use the handwashing station near the dish machine when sanitizing her hands. She stated that the cooks were the only staff allowed to use the sink near the stove. She stated she was not responsible for defrosting frozen food items. Interview on 03-06-24 at 01:48 p.m., Dietary Aid A stated he had been responsible for assisting the cook plating trays with desserts and making sandwiches. He stated he was instructed to wash his hands near the dish machine. He stated he does not thaw foods and was not aware who thawed the ground beef on 03-05-24. Interview on 03-06-24 at 01:48 p.m., Dietary Aid B stated that she had a split role at the facility in dietary services and in laundry services. She stated her job responsibilities in the kitchen were to assist the cooks plate trays. She stated she was instructed to use the hand washing station near the dish machine. She stated that the cooks only use the handwashing station near the stove. She stated that the cooks thaw frozen food items in the sink near the stove. She stated the sinks used to thaw foods were sanitized before and after foods were thawed. She stated once the frozen food item was placed in the sink, cold water would run over the food real low. She stated that she did not thaw any food items and was not aware who thawed the ground beef loafs on 03-05-24. Interview on 03-06-24 at 02:04 p.m., [NAME] A stated that the kitchen had 2-handwashing stations in the kitchen. She stated that she used both handwashing stations because as the cook, she was all over the kitchen. She stated that the Floater took the ground beef loafs from the freezer and placed them in the sink near the stove in the morning of 03-05-24. She stated that the Floater had just placed the ground beef loafs in the sink just prior to Surveyor A entering the kitchen on 03-05-24 at 11:47 a.m. and was not sure why he had not turned on the water immediately after placing the loafs in the sink. She stated that the Floater had turned on the water after Surveyor A entered the kitchen. She stated that she checked the water periodically during the thawing process until it was thawed. She stated that the thawing policy stated that frozen foods were placed under running water between 2 - 3 hours or until thawed. She stated it was normally the cook's responsibility to remove items from the freezer and place them in the sink to be thawed. She stated due to her recent illness, the Floater went in and out of the freezer for her so she would avoid exposure to the cold temperature. She stated that the Floater was also helping in the kitchen stocking items from the food shipment that had been received the morning of 03-05-24. She stated depending on the size of frozen food items, it would have been placed in a pan before being placed in the sink. She stated the pan would be tilted for running water to flow over the food item and not be stopped up under the pan. She stated that the ground beef loafs were too big to fit in pans, therefore the Floater placed the meat loafs in the sink directly. She stated she did not witness the Floater disinfect the sink before or after placing the ground beef loafs in the sink, but he should have. She stated she does not know who took the ground beef loafs out of the sink once they were thawed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 7 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 - Few Interview on 03-06-24 at 02:44 p.m., the Dietary Manager (DM) stated that the kitchen had 2-handwashing sinks. She stated that the cooks used the hand washing station near the stove for easy access while preparing meals, but all other staff were to use the handwashing station near the dish machine. The DM stated that the sink near the stove had also been used to defrost food. She stated that the sink would have been disinfected before and after any foods were thawed within. She stated that the Floater placed the ground beef loafs in the sink on 03-05-24 just prior to Surveyor A entering the kitchen at 11:47 a.m. She stated that Floater then turned on the cold water to run over the ground beef loafs. She stated that the Floater sanitized the sink prior to placing the frozen items in the sink. She stated per policy defrosted items were to be submerged in and ran under cold water. The DM stated that the sink was not stopped up while the meat was thawed, and the meat was not submerged in water. She stated after viewing a picture Surveyor A took of the meat in the sink at 12:24 p.m. that the water ran over only 1 of 3 of the 10lb frozen meat loafs. She stated that frozen items were normally placed into a pan and then into the sink, but that the ground beef loafs were too long to fit the pans available to the staff in the kitchen. She stated the Floater put the frozen meat in the sink on 03-05-24, walked away just for a moment and then came back and turned on the cold water to run over the frozen ground beef. She stated that she saw the Floater sanitized the sink before placing the meat in the sink. She stated that [NAME] B removed the thawed meat from the sink and placed the meat on a pan and then placed it in the refrigerator overnight. She stated that the process for sanitizing the sink before and after thaw food items consisted of: wash, rise and sanitize with a sanitization solution kept under the steam table for easy access. Interview on 03-07-24 at 10:34 a.m., Dietitian stated that according to storage regulations, it was typically recommended that frozen foods be thawed under cold running water. She stated depending on the size and quantity, frozen meats would be placed in a pan in the sink under running water as long as the water would not be stagnant. She stated the sinks at the facility were small, making it difficult to meal prep and have a handwashing station. She stated after reviewing the handwashing policy on thawing foods, despite policy, it was not necessary to submerge the meat in water based on her food handling professional experience but would rather be more concerned that the water was running and under 70 degrees. Interview on 03-07-24 at 02:59 p.m., the DON stated that she was informed by the DM of the frozen ground beef in the sink. She stated that the DM was an experienced and educated DM. She stated that the DM and her would be looking at the thawing and sink sanitizing processes to ensure that the kitchen staff were educated on proper procedures. She stated that staff were not to thawed in foods in the handwashing or dishwashing stations to avoid cross contamination. She stated the Floater who placed the meat in the sink was off shift on a flight and unreachable due to his travel. Interview on 03-07-24 at 03:31 p.m., Administrator stated that the Health Department had recommended that the kitchen sink near the stove could also be used as a handwashing sink since the other sink was rather far away from where the cook's preparation station. She stated that it was her expectations that the kitchen staff follow the frozen food thawing policy: placing foods on pans and running under cold water and that the sink was to have been sanitized before and after any frozen foods were placed in it. She stated that the in-service documentation would be provided on thawing food and sanitizing sinks. Unsuccessful interview attempts to interview the Floater were made on 03-06-24 at 04:20 p.m., on 03-07-24 at 09:02 a.m., and 03-07-24 at 10:09 a.m. Record review of Food and Preparation and Service revised date November 2022 revealed that, Policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 8 of 9 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 675538 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sugar Land Health Care Center 333 Matlage Way Sugar Land, TX 77478 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 - Few Statement. Food and nutrition service employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. General Guidelines 2. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Thawing Frozen Food 1. Foods are not thawed at room temperature. Appropriate thawing procedures included: B. completely submerging the item in cold running water (70 degrees or below) that is running fast enough to agitate and remove loose ice particles . Record review of the in-services dated 03-07-24 on Sink Sanitizing and Thawing Frozen Foods conducted by the DM. Cleaning and Sanitizing Requirements: 1. Who is responsible: If the sink is used to thaw/wash food products, it should be cleaned and sanitized first by the person (i.e. cook, dietary aid etc.) that will be placing the food item into the sink to be thawed/washed etc. 2. The practice of cleaning and sanitizing the sink is done prior to the product being placed in the sink and after the product is taken out of the sink. The person responsible for taking the product out of the sink is responsible for cleaning and sanitizing the sink when the product is removed. 3. The sink will be washed, rinsed, and sanitized (with the QA solution) prior to food products being placed into the sink and when the food product is removed from the sink. 4. If a product is placed in the sanitized sink to be thawed/washed, then cold running water should be used over the product for proper thawing. The person (i.e. cook, dietary aid etc.) that placed the product into the sink for thawing will be responsible for periodically checking the food to rotate and see if the product is thawed. Once the product is thawed it will be used to prepare the dish or stored in the cooler with a label and date. Record review of the Texas Food Service Establishment Rules Field Inspection Manual dated October 2015 recelaedd that, §228.75(C) (2) Temperature and Time Control. (C) Thawing. Except as specified in paragraph (4) of this subsection, time/temperature control for safety (TCS) food shall be thawed: (2) completely submerged under running water: . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675538 If continuation sheet Page 9 of 9