Health inspection·October 31, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident (Resident #102) reviewed for care plans. The facility failed to ensure Resident #102 had a care plan that reflected her new 7/8/24 diagnosis of unspecified convulsions (seizures). This failure could cause the staff to miss needed safety measures on the resident and place the resident at risk of injury from seizures. Findings include: Record review of Resident # 102's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Diabetes, Hypertension (high blood pressure), Reflux, Dysfunction of Bladder and High Cholesterol. The face sheet also revealed a new diagnosis of Unspecified Convulsions with an onset date of 7/8/24. Record review of Resident #102's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, which indicated the resident's cognitive ability was severely impaired. The MDS did list Seizure Disorder or Epilepsy as an active diagnosis. Record review of Resident #102's undated Care Plan reflected, Unspecified Convulsions listed in the diagnosis list, but not listed in the Problem, Goal, or the Intervention areas of the care plan. Record review of Resident #102's Progress notes reflected the following: 7/8/24 at 08:44 am, staff witnessed pt (patient) having a seizure x 2. 7/9/24 at 09:07 am Continues in hospital. 7/10/24 at 07:53 am resident had returned to the facility and was sitting at nurse's station when vital signs were taken. In an interview on 10/31/24 at 10:25 am the MDS Nurse reviewed Resident #102's care plan and stated, the new July diagnosis of seizures was not added to the care plan. She stated, I don't know how I missed updating the care plan. I did everything else. The MDS Nurse stated the policy was to update the care plan 1 week after the MDS closure date. It was important to keep the care plan current so Page 1 of 13 675546 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff knew how to follow the plan of care for each resident. The potential negative outcome to residents if the care plan was not current then staff could miss something in the care of the residents. In an interview on 10/31/24 at 11:23 am with the DON, she stated the policy is to update the care plan as new diagnosis come up. She stated it is important to keep the care plan current so that all staff are on the same page with care and all staff can see what is going on in the chart. The DON stated the negative outcome to residents if the care plan is not current could be staff could miss treatments or get inappropriate treatments. In an interview on 10/31/24 at 11:27 am with the ADM, she stated the policy on updating diagnosis related to care plan is that once they get a diagnosis the care plan should be updated. She stated it is important to keep the care plan current to make sure residents get the care needed and nothing is missed. The ADM stated the potential negative outcome to residents if the care plan is not current would-be staff could give drugs that are not needed or miss treatments needed. She stated staff must know to know the information, so they could treat the residents best. In an interview on 10/31/24 at 11:30 am with the BOM, she stated that she is unsure of the policy on updating diagnosis related to care plans as she does not do care plans. She stated it is important to keep the care plans current because that is what staff use to go by for resident's care. Staff will not have the appropriate information to provide the care for residents if the care plan is not current. BOM stated the potential negative outcome to residents is they will not get the care needed. A record review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated 2001 with a last revision date of 2016 reflected the following: The comprehensive, person-centered care plan will: o Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. o Incorporate identified problem areas. o Reflect treatment goals, timetables and objectives. o Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 675546 Page 2 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to label and date all food items located in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer on 10/29/2024, 10/30/2024, and 10/31/2024. 2. The facility failed to effectively reseal all food items in the walk-in refrigerator and walk-in freezer to prevent contamination or spoilage on 10/29/2024, 10/30/2024, and 10/31/2024. 3. The facility failed to dispose of expired foods items located in the walk-in refrigerator. 4. The facility failed to clean the ice machines properly resulting in the presence of slime and an unidentified black substance build up in the ice machines on 10/29/2024 and 10/30/2024. 5. The facility failed to ensure kitchen staff held cold foods (fortified vanilla pudding and fruit cups) at a temperature of 41 degrees Fahrenheit or less on 10/30/2024. 6. The facility failed to ensure Resident #38, and Resident #84 were free from potentially hazardous food when they were served vanilla pudding at lunch on 10/30/2024 that was held at inappropriate temperatures. 7. The facility failed to ensure one hand-washing sink in the kitchen next to the dishwasher was easily accessible when it was cluttered with two brooms, a dustpan, dishwasher rack, a meal cart with dirty trays, and the trash receptacle was blocked by a box of gloves and rolls of trash bags on top of the trash lid. 8. The facility failed to ensure the dry food pantry floor was free of dust, dirt, food particles, thick white stains, and red residue. 675546 Page 3 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 These failures could place residents and staff at risk for health complications, food contamination, and foodborne illnesses and at risk for unsanitary conditions. Level of Harm - Minimal harm or potential for actual harm Findings included: Residents Affected - Many During the initial tour of the kitchen on 10/29/2024 at 07:05 AM the following was observed: The reach-in refrigerator contained two trays of fresh cut cantaloupe and green melon cups that were not labeled or dated. One of the fruit cups was open with the lid off and not properly sealed. The walk-in freezer contained an open clear plastic bag of fried okra that was not labeled, dated nor properly sealed. The fried okra was exposed to air. A small clear plastic bag of something yellow in color was tied at the top. It was not labeled nor dated. The walk-in refrigerator contained a square clear container, with a lid, of an orange-colored gelatinous substance that was not labeled nor dated. There was also a square clear container of sliced beets. It was labeled Beets Pureed and dated 10/25/2024. Four trays of premade shredded cheese cups were stacked, labeled, and dated 10/22/2024. The ice machine was observed to have multiple white streaks and stains consisted with hard water on both exterior sides of the stainless-steel sides of the machine from the top of the door, extending all the way to the floor. The prefilter container that was on the wall next to the ice machine was clear plastic and the filter inside was green in color. The lid of the ice machine was propped open by an empty cardboard box. Observation of the inside of the ice machine revealed a black/brown substance on the inside of the chute sending ice into the ice machine storage bin. The substance resembled slime, dirt, or mildew and could be removed with a paper towel. Water drops were dropping off the soiled areas into the ice and on the surveyor's cell phone while the surveyor was taking photos. The storage bin was full of ice cubes. One hand washing sink in the dishwasher room was cluttered with two brooms, a dust pan, a dishwasher rack on the floor, a meal tray cart full of old meal trays from the previous day, chemicals hanging from the shelf above sink, a trash receptacle next to the sink with two rolls of trash bags and a box of vinyl exam gloves on top of the trash can top so that the trash can could not be opened. The dry food pantry floor was dusty, dirty, stained, and visually soiled with gum, food, and trash on the floor. There was a thick white residue on the floor in the corner with some red staining on top that appeared to be ketchup or other type of condiment. During an observation and an interview on 10/29/2024 at 07:20 AM, CK A stated that the fresh fruit cups in the reach-in refrigerator should have been labeled and dated. CK A said he thought the fruit cups might have been prepared on 10/28/2024, but he was not sure because the food was not dated. Observed CK A remove the fruit trays from the reach-in refrigerator and place the trays on the kitchen counter and walked away. CK A stated that bag of fried okra in the walk-in freezer should have been sealed in a zip top bag to keep the food fresh and avoid freezer burn. CK A stated the other container in the freezer was fried chicken nuggets and stated the food in the freezer should have been properly sealed, labeled, and dated to maintain freshness. CK A stated he would throw away the bag of okra and chicken nuggets because he saw freezer burn on the food. CK A stated he did not know what the container of orange stuff in the walk-in refrigerator was because it was not labeled. He stated he thought it could be cheese sauce but was not sure. CK A stated that the container labeled Beets 675546 Page 4 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Pureed was wrong and it was expired. Observed CK A leave the unlabeled container and the beets container in the walk-in refrigerator. CK A stated it was the facility's policy to properly store, label, and date all food and all kitchen staff shared that responsibility. CK A stated that it was important to label and date the food to ensure the food was fresh and so that kitchen staff knew what the food was. CK A stated old food could make a resident sick and it was important to serve residents fresh food. He did not know how long freshly made food could stay in the refrigerator. He said, 3 days or maybe 7 days. I'm not really sure. CK A stated he was not responsible for cleaning the ice machine. During an interview on 10/29/2024 at 07:28 AM and 11:00 AM, the DM stated it was the facility's policy to properly seal, label, and date all food and all kitchen staff shared that responsibility and that was her expectation. The DM stated it was important to seal, label, and date the food to ensure the food was fresh. She stated that it was her expectation that kitchen staff would throw away open food or seal it in zip top baggies and label and date food that would be kept. The DM said, I'm not going to lie. Packing, labeling, and dating the food is a real problem. She stated not storing food properly could lead to cross-contamination and could result in a negative outcome to the residents that ate that food. The DM stated that they used a vendor that provided cleaning and maintenance on the ice machine, but she did not know the details. She would have to ask the maintenance worker. The DM stated kitchen staff do not clean the ice machine or change the filter. The DM stated the dietary aides were supposed to sweep and mop the dry food pantry every day. She stated that the soiled area on the floor was from preparing snacks on 10/28/2024 and the staff did not clean the floors. The DM stated her expectations were that the kitchen floors were swept and mopped daily. She stated there was a risk of cross contamination with dirty floors. The DM stated that both she and her staff use the hand washing sink by the dishwasher. The DM stated it was her expectation that staff wash their hands when coming from the dishwasher to the kitchen as that area (by the dishwasher) was considered the dirty area. During a follow up tour of the kitchen on 10/30/2024 at 08:04 AM the following was observed: The reach-in refrigerator contained one tray of fresh cut cantaloupe and green melon cups that was not labeled. One of the fruit cups was dated 10/29/2024, but none of the other fruit cups were dated. Observation of the walk-in refrigerator revealed a block of margarine that was not properly sealed and open to the air. A clear plastic bag containing slices of bread in individual plastic baggies and individually packaged oatmeal cookies were not labeled nor dated. There were three trays of premade shredded cheese cups dated 10/22/2024 with loose cheese all over the top of the tray. Observation of the walk-in freezer revealed an open bag of French fries exposed to the air, which was not labeled nor dated. The inside of the ice machine was unchanged from 10/29/2024. Observation revealed a black/brown substance on the inside of the chute sending ice into the ice machine storage bin. The substance resembled slime, dirt, or mildew. The prefilter container that was on the wall was green. During an interview on 10/30/2024 at 08:27 AM and 9:43 AM, the DM stated it was the kitchen staff's responsibility to clean the outside of the ice machine. The kitchen staff had not been trained on cleaning the inside of the ice maker. The maintenance worker had a log and cleaned the inside of the ice machine. The DM said she thought it was cleaned once a month. The DM did not have a copy of that 675546 Page 5 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many log. The Surveyor showed the DM the inside of the ice machine and the DM stated she never checked inside the ice machine to see if it was clean or not. The DM stated the area that ice cubes came from had a black/brown slime which was cross contaminating the ice and could cause foodborne illnesses in the residents that consumed the ice in their drinks. The DM stated, The residents could be sick and it's not the food, it's the ice. The DM stated the facility's policy for food storage was that freshly made food could be kept for three days before discarding and throwing it away with day 1 being the day the food was prepared. The DM stated she kept an eye on food, but all kitchen staff were responsible for checking and throwing away expired food by the use by date. The DM had trained kitchen staff on the policy. The DM stated staff were responsible for cleaning their own areas. There were two kitchen aides that were responsible for cleaning the dishwasher area. They were expected to sweep and mop the area and put away the mop, broom, and dishwasher crates. The mop, broom, and dustpan should be stored in the corner of the room, not in front of the sink. After cleaning, staff should be using that sink to wash their hands. During an observation in the kitchen on 10/30/2024 at 11:01 AM, revealed several small plastic cups filled with puddings on trays that were stacked on the kitchen counter. Bowls of canned fruit was observed stacked on a meal cart in the kitchen. During an observation in the kitchen on 10/30/2024 at 11:35 AM, CK A tested the temperature of the vanilla pudding cups with a pocket dial thermometer, and it displayed over 70 degrees Fahrenheit. CK A got a different thermometer that had not been used on the steam table and retested the pudding with a digital thermometer which displayed 66 degrees Fahrenheit. CK B stated CK A was doing it wrong, and it needed to be measured using Celsius. CK A rechecked the pudding for a third time with a digital thermometer which displayed 19 degrees Celsius (66.2 degrees Fahrenheit). CK A tested the temperature of the fruit cups with the same digital thermometer which displayed 44.4 degrees Fahrenheit. During an interview with the DM and CK B on 10/30/2024 at 11:45 AM, CK B stated the vanilla pudding was made with Non-Dairy Frozen Soft Serve Mix, Pie Filling mix, and milk, and had been stored in the reach-in refrigerator. Both the DM and CK B stated that cold food should be held at 41 degrees or lower. CK B stated the fruit cups had been made up that morning, but later stated they had just been pulled out of the walk-in refrigerator. Both the DM and CK B stated their plan was to put the food back in the refrigerator, bring it down to the proper temperature of 41 degrees or lower, and serve it for lunch. The DM stated that residents could get foodborne illnesses by eating food that was not kept at the appropriate temperature. During an observation on 10/30/2024 at 11:53 AM, the vanilla pudding was observed in a bowl of ice on the kitchen counter and in the kitchen sink. At 11:53 AM, CK B led the surveyor to the dry pantry room and showed the surveyor the two mixes used to make the pudding. Review of the Non-Dairy Frozen Soft Serve Mix instructions, reflected to mix, cover, and place in refrigerator (less than 40 degrees [Fahrenheit]). Review of the Pie Filling mix instructions revealed to mix with milk and keep at refrigerated temperatures until served. During an observation and interview on 10/30/2024 at 12:00 PM, CK B and DM both stated they pulled the fruit cups and would serve ice cream instead. They said they would not serve the pudding. Containers of pudding were observed still on the kitchen counter. An observation of the main dining room on 10/30/2024 at 12:01 PM, revealed the pudding had been served to two residents (Resident #38 and Resident #84). Neither one of the residents ate the pudding. 675546 Page 6 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Staff took the pudding away. Level of Harm - Minimal harm or potential for actual harm During an observation in the kitchen on 10/30/2024 at 12:15 PM, the surveyor observed all the pudding had been throw in the trash. The Surveyor pulled a pudding cup out of the trash, smelled it, and did not observe any foul odor. Residents Affected - Many During an interview and record review on 10/30/2024 at 03:30 PM the MAIN D. Director stated he just cleaned the inside of the ice machine located in the kitchen because the DM told him the survey team had found a concern. He stated the inside of the ice machine was covered with slime and mold. He stated he had not cleaned the inside of the ice machine in over a year since [VENDOR] was hired to provide service to the ice machine. He provided the surveyor with a copy of a contractor's invoice dated 07/08/2024 which revealed [VENDOR] provided a repair and disassembled all parts and found a large amount of slim and mold on water trough, water pump, water curtain, and water distribution tray. Cleaned and sanitized all parts. Put machine on a cleaning cycle. The MAIN D. stated he had worked at the facility for 20 years and had not cleaned the ice machine in 2024 nor checked the inside of the ice machine because [VENDOR] was supposed to be cleaning it and the facility paid [VENDOR] $800 to clean the inside of the machine. He did not know what the recommended cleaning schedule was based on the manual. The Surveyor requested a copy of the vendor's contract and manufacturer's manual. The MAIN D. stated kitchen staff did not clean the inside of the ice machine. During an interview and record review on 10/30/2024 at 03:50 PM the MAIN D. stated he was incorrect earlier as the facility did not have a contract with the vendor. He stated he called [VENDOR] to service the ice machines once a year. Again, the MAIN D. stated he had not cleaned the inside of the ice machines because they paid [VENDOR] $800 to do that. The MAIN D. stated there were two ice machines listed on the [VENDOR] invoices. He provided the surveyor with three invoices dated 07/08/2024, 08/17/2023, and 10/17/2022. The invoices had two ice machines listed and the MAIN D. stated the first ice machine was the ice machine in the chapel, but it was broken and not used. The bottom machine with the information listed about the large amount of slim and mold was the ice machine in the kitchen that he just cleaned. The MAIN D. stated he changed and put in a new filter because the old filter was dirty. He stated he oversaw checking and changing the filter. During an observation on 10/30/2024 at 03:51 PM of the second ice machine in the chapel revealed it was in use. The inside revealed some black marks/spots that appeared to be mold or mildew. During an interview on 10/30/2024 at 03:54 PM the AAD stated that the ice machine in the chapel was used for residents during activities or special events. During an observation and interview in the kitchen on 10/30/2024 at 05:02 PM, revealed the reach-in refrigerator contained one tray of what appeared to be cups of vanilla pudding that was not labeled nor dated. The DM stated those were vanilla pudding cups that had been remade at lunch on 10/30/2024. During an interview on 10/30/2024 at 05:02 PM, CK D stated she had received training before she started work. She was knowledgeable on the facility's policy on labeling, dating, and properly sealing and storing food. CK D stated that if she saw food that was not properly labeled, dated, or sealed, she would throw it out. CK D had knowledge of the proper temperatures for hot and cold food and said it was important to have foods stored and distributed properly to avoid possible foodborne illnesses. CK D stated she had never cleaned the ice machine. CK D stated she would mop or sweep the pantry floor occasionally if needed. 675546 Page 7 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 10/31/2024 at 08:11 AM, DA C stated she had received training before she started work. She had work at the facility for 8 years. She was knowledgeable on the facility's policy on labeling, dating, and sealing food and keeping food at the proper temperatures and stated it was important so that resident do not get sick. DA C stated she had never cleaned the inside of ice machine. She stated food could be stored for 7 days before discarding. DA C stated she washed dishes, swept, mopped, and cleaned the floors in the kitchen daily and stored the mop, broom, and dustpan in the back room. She did not clean the pantry floor. During an interview on 10/31/2024 at 8:13 AM, CK B stated she had received training on her job duties before she started work. She stated all food must be sealed properly, labeled, and dated to know which food had to be served first. She stated it was important to label, date, and store food properly to maintained freshness and prevent cross contamination. It was important to have a clean kitchen because that is where the food was being stored and prepared. CK B stated she does not clean the inside of ice machine. CK B stated she cleaned the kitchen and the pantry floor daily. She stated it was important to have a clean kitchen because that was where the food was being stored and prepared. CK B stated not cleaning the pantry floors could cause cross contamination with the food. During an observation of the walk-in freezer on 10/31/2024 at 8:15 AM revealed an opened bag of chicken nuggets that were not properly sealed, labeled, or dated. During a telephone interview on 10/31/2024 at 09:40 AM the RD stated he was the licensed dietitian for the facility, and he came to the facility 3 times a month. His expectation was that foods would be dated, labeled, and properly sealed to maintain the quality and texture of the food and prevent the food from spoiling. Food not property labeled, dated, and sealed could lead to illness if the residents consumed expired or old food. The RD stated that he did an in-service training last month on proper labeling and dating of food because that had been an issue. He stated it was the DM's responsibility to ensure all food were labeled and dated. The RD stated he did look inside the ice machine during his monthly tour and was told it was cleaned on 10/30/2024. He stated serving residents ice from a machine that was not properly cleaned and sanitized could led to illness and would not meet his expectation. He had knowledge of proper food temperatures and did an in-service training on 10/30/2024 about food safety and proper temperatures. The training stated that if food was not held at the proper temperature, it was recommended to throw out the food because the food was not safe to eat. The RD stated residents eating food held at improper temperatures had the potential to cause illness. During an interview on 10/31/2024 at 12:30 PM, the ADM stated all food should be labeled and dated including dry goods, refrigerated items, and frozen food with the date packages were opened or when the food was prepared. The ADM stated that the DM and RD was responsible for monitoring food storage, labeling, and dating in the kitchen. The ADM stated all the staff knew to date and label the food, but They did not do it 100% of the time. She stated this did not meet her expectations. The ADM stated she was aware the RD had reported an issue of not labeling, dating, and properly sealing food and they had been working to resolve the issue. The ADM stated food not properly stored, labeled, and dated could cause residents to become ill due to foodborne illness and it could affect the texture or taste of the food. The ADM was knowledgeable about the proper temperature of cold foods to be held at or below 41 degrees Fahrenheit and stated it was the cooks' responsibility to monitor food temperatures on the line and the DM and the RD were also responsible for monitoring food temperatures. The ADM stated that it was the DM's responsibility to ensure the kitchen was cleaned. They have a contract with [VENDOR] and Maintenance Supervisor should ensure the ice machine was properly cleaned. The ADM stated that the ice machine was cleaned as often as it should have been and that did not meet 675546 Page 8 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many her expectation. The ADM stated an unclean kitchen and dirty ice machine with slime and possible mildew could cause legionnaires disease and/or foodborne illness. The ADM stated the schedule for cleaning the kitchen was posted in the cleaning area in the kitchen. The ADM stated the cooks and dietary aides were responsible for cleaning the pantry floor and the DM was responsible for monitoring to ensure the kitchen was cleaned appropriately. She stated she thought the area by the hand washing sink was cluttered because staff were in a hurry. The clutter and dirty pantry floor did not meet her expectations and stated it was important to keep the kitchen clean to prevent potential illness. Record review of kitchen in-service trainings revealed on June 14 (no year listed), staff were trained on food temperatures. The training reflected, If state comes in and ask you any questions .Cold items 40 degrees or below for milk, fruit, or anything being served as a cold item. The RD provided training on Labeling and dating on 09/26/2024 and Keeping food safe on 10/30/2024. Training included, For cold foods, leave in fridge until ready to serve to maintain temperature of 40 F or below. The training also reviewed the policy Cooling and Reheating Foods approved 10/01/2028, which stated, Leftover food much be labeled, dated, and reused within 48 hours. Record review of the facility's policy Food Storage revised 06/01/2029 revealed: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state and US Food Codes and HACCP guidelines. Procedure: 2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the indigo ice machine manual titled Installation, Operation, and Maintenance Manuel revealed: Cleaning and Sanitizing General You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company .An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Cleaning/Sanitizing Procedure This procedure must be performed a minimum of once every six months. 675546 Page 9 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 The ice machine and bin must be disassembled cleaned and sanitized. Level of Harm - Minimal harm or potential for actual harm All ice produced during the cleaning and sanitizing procedures must be discarded. Removes mineral deposits from areas or surfaces that are in direct contact with water. Residents Affected - Many Preventative Maintenance Cleaning Procedure This procedure cleans all components in the water flow path and is used to clean the ice machine between the bi-yearly cleaning/ sanitizing procedure. Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation. Wipe surfaces with a damp cloth rinsed in water to remove dust and dirt from the outside of the ice machine . Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. Record review of facility's policy General Kitchen Sanitation approved 10/01/2028 revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 7. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of kitchen weekly cleaning schedule revealed ice machine maintenance was listed as a task on 01/05/2024 and was not marked or initialed completed. The facility provided a logbook documentation from Direct Supply Tels regarding the ice machine maintenance. It stated Check filters (if present), clean coils, sanitize interior, delime, as necessary. Recurrence: Every 6 months. Next Due: In November 2024 Assigned to: Unassigned. 675546 Page 10 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0812 Category: Ice Machines Level of Harm - Minimal harm or potential for actual harm Marked done by MAIN D. on 05/31/2024, with a note about purchasing new filter. Record review of the facility's policy Food Holding and Service revised 06/01/2029 revealed: Residents Affected - Many Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. 5. Cold Food Temperatures d. Maintain all cold prepared items at a temperature of 41 °F or below until ready to serve. Do not remove from refrigeration until ready to serve. Record review of facility's policy General Kitchen Sanitation approved 10/01/2018 revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 1. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of kitchen weekly cleaning schedule dated January 1, 2024, through September 30, 2024, revealed dry storage clean and organize was listed as a weekly task. On 07/11/2024, cleaned and swept pantry. The daily cleaning schedule dated July 1, 2024, through October 12, 2024, listed: Floors (swept and mopped each shift) assigned to All Staff sinks (each use) clean and sanitize assigned to All Cooks food carts assigned to Aides/Prep. 675546 Page 11 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one of one facility reviewed for environment in that: 1. The facility failed to properly maintain sanitary emergency eyewash station in the kitchen when the protective eyewash covers were not properly positioned, not capped when not in use, and had a roll of paper towels inside the basin. The facility failed to keep the area clear and accessible to kitchen staff when the area was cluttered and blocked with brooms, a dustpan, a meal cart with soiled meal trays, a trash can, box of gloves, and rolls of trash bags. These failures could place staff at risk for an unsafe, unsanitary, and uncomfortable environment. Findings included: During the initial tour of the kitchen on 10/29/2024 at 07:05 AM the following was observed: A sign on the wall reflected, Emergency Eyewash Keep Area Clear. Test All Emergency Equipment Weekly. An emergency eyewash station was mounted to the wall next to the hand washing sink in the dishwasher room. The plastic bowl basin had a roll of paper towels inside it. The basin appeared dirty with a white film or residue on it. The orange protective eyewash flip-top dust covers were flipped back and open exposing the spray-type head. The protective eyewash flip-top dust covers were not capped. The area was cluttered and blocked by a closed trash can with a box of vinyl exam gloves and rolls of trash bags on top of trash can, two brooms, a dustpan, and a meal tray cart full of old meal trays from the previous day. During an interview on 10/30/2024 at 9:43 AM, the DM stated staff were responsible for cleaning their own areas. There were two kitchen aides that were responsible for cleaning the dishwasher area. They were expected to sweep and mop the area and put away the mop, broom, and dishwasher crates. The mop, broom, and dustpan should be stored in the corner of the room, not in front of the emergency eyewash area. The DM stated there could be cross contamination from the dirty broom and dustpan sitting that close to the emergency eye washing station. The DM stated that she had trained staff to keep the eye washing area clear, clean, and accessible. The surveyor requested a copy of the eye washing station training, policy, and procedures. During an interview on 10/30/2024 at 05:02 PM, CK D stated she was unaware that there was an emergency eye washing station and had not received any training about that. She was not sure what she would do if she got something in her eyes. She would probably tell her manager and go into the bathroom. During an interview on 10/31/2024 at 08:11 AM, DA C stated she washed dishes, swept, mopped, and cleaned the floors in the kitchen daily and stored the mop, broom, and dustpan in the back room. DA C stated she was not aware there was an emergency eye wash station and if something got in her eyes, she would tell her manager. 675546 Page 12 of 13 675546 10/31/2024 Trinity Care Center 1000 E Main St Round Rock, TX 78664

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of the kitchen on 10/31/2024 at 08:15 AM, revealed the emergency eye wash station area was blocked with a trash can on the floor in front of the sink. During an interview on 10/31/2024 at 9:43 AM, with the DM the surveyor requested the eye washing station policy, procedure, or training for the second time. The DM stated she did not know if they had a policy, but she did train her staff on where the sink was located and how to use it as part of staff orientation. The DM did not have any documented training regarding the eye wash station. She stated it was the Maintenance Director's responsibility to service the station and make sure it was in working condition. The DM was not sure how often that was done. She expected her staff to keep the area clear and accessible. During an interview and record review on 10/31/2024 at 11:15 AM the DM provided the surveyor with Inspect eyewash stations task sheet that she received from the Maintenance Director. The DM stated that the task was assigned to the Maintenance Director, and he noted all pass if the inspection passed. Record review of the Inspect eyewash stations task sheet revealed instructions, Verify the eyewash station is on the same level as the hazard and accessible and unobstructed. Verify protective eyewash covers are properly positioned, clean, and intact. Verify that eye wash station was disinfected weekly. Verify capped when not in use. During an interview on 10/31/2024 at 12:30 PM, the ADM stated there was not an emergency eye washing station policy. If kitchen staff got something in their eyes, she would expect them to go to eye washing station and flush their eyes out. The ADM stated that the DM was responsible for ensuring staff had access to the emergency eye washing station and for ensuring the kitchen was properly cleaned. The ADM stated if staff got dishwashing chemicals or something else in their eyes and could not access the emergency eye washing station they could trip and fall and injury themselves. She stated she thought the area by the eye wash station was cluttered because staff were in a hurry. The clutter did not meet her expectations and stated it was important to keep the kitchen clean to prevent potential illness. 675546 Page 13 of 13