Health inspection·August 6, 2025

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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.The facility failed to ensure:- the dish machine was not sanitizing- the ice machine ice chute and air intake vent were not clean- in the reach in cooler chocolate milk pints were out of date - 2 packages of dry pasta were no re-closed after opening- freezer #1 had a package of frozen fried eggs open and not secured closed- the pan rack had 8 pans stacked wet, 1 with food debris present and 1 greasy full size baking sheet- the deep fryer had cornmeal-like debris floating on the surface of the oil, stuck to both fry baskets, and covering the drain tray.- the spice rack had brown sugar and powdered sugar packages opened and not re-sealed.- the 3 compartment sink was not sanitizing and the QA test strips were out of date.These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included:During observations, interviews and record reviews on 08/04/2025 of the kitchen the following was noted:At 10:43 AM the DM tested the dishwashing machine and the chlorine test strip did not react indicating it was not sanitizing. The container of sanitizer connected to the machine was empty. She said when she checked the machine earlier around 8:30 AM and it was sanitizing and she logged it on the sanitizer log. The dish machine sanitizing log indicated it tested at breakfast on 08/04/2025 at 50 ppm. The manufacturer's recommendations accepts 50 ppm-200 ppm as adequate for sanitizing. At 10:46 AM the ice chute inside the ice machine was swiped with a clean paper towel and returned with some black and brown debris and discoloration. The air vent above the ice machine door was caked with greasy, black lint-type debris. At 10:47 AM the DM said the ice machine vendor cleaned the machine and was at the facility on Friday, 07/25/2025 and Monday, 07/28/ 2025. She said dietary did not clean the inside of the machine and said the vendor only came every 6 months and maintenance called them to come do the routine cleaning. She said she had only been at the facility for 4.5 months and this was the first time she had seen him. She said dietary wiped down the gasket area and the lid routinely as needed or daily.At 11:00 AM in the 2 door reach in cooler there were 23 pints of chocolate milk dated 08/01/25. The DM removed the out of date chocolate milk pints from the cooler. She said they only had 1 resident that drank chocolate milk.At 11:08 AM in the dry pantry there was 1-16 oz box of lasagna sheets opened and not re-sealed and 1-10 lb. bag of elbow macaroni that was open and not re-sealed. The DM said staff were to close up bags and boxes after opening or place items in zippered bags. At 11:10 AM in freezer #1 in the pantry there was 1 unlabeled, thin plastic bag containing what appeared to be frozen, fried eggs that was opened and the product was visible with nothing covering the product. Freezer frost had fallen from the shelf above the frozen fried eggs into the bag. The DM said 2 residents ate the frozen fried eggs because they could eat them easily with their fingers. She took the bag and tied it in a knot so it was closed and returned it to the freezer.At 11:20 AM the following pans on the pan rack were stacked wet.1-full size 4 deep stainless steel pan1-1/2 size 6 deep stainless steel pan1-1/2 size 8 deep stainless steel pan3-1/4 size 6 deep stainless steel pan-1 had visible white food debris 1-1/4 size square 4 deep stainless steel pan1-1/4 size square 2 deep stainless steel pan 1-full size baking sheet was greasy and had visible solidified grease droplets in the center of the sheet. The baking sheet was greasy to the touch on the cooking surface and the bottom of the tray. At 11:23 AM the deep fryer had cornmeal-like debris floating on the surface of very dark oil, cornmeal-like debris was stuck to both fry baskets, and cornmeal-like debris was covering the drain tray. At 11:25 AM on the spice rack there was 1-1 lb. bag of brown sugar opened and not re-sealed and 2-1 lb. boxes of powdered sugar were opened and placed inside an open zip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675709 If continuation sheet Page 2 of 3 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 675709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Timberidge Nursing and Rehabilitation Center 315 W Gibson Jasper, TX 75951 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 - Many FORM CMS-2567 (02/99) Previous Versions Obsolete bag.At 11:40 AM the DM said she knew the dishes and pans were not to be stacked wet. She said she was not sure if the staff knew the pans had to be dry when stacked. She said she would have to ask [NAME] A which she did not do. She said she was responsible for training staff on kitchen procedures and monitoring them to ensure compliance with regulations and policyAt 11:42 AM [NAME] A said the pots, stainless steel pans, and dishes were to be stacked when they had air dried.At 11:48 AM the dish machine was checked again after the DM had connected a fresh container of sanitizing solution and the solution was not pumping into the machine. The DM said maybe the maintenance man could get it fixed.At 11:55 AM the DM said the three compartment sink was not used for sanitizing. She said dishes, pans, pots and other items were washed in the sink and then placed in the dish machine for sanitizing. Quaternary Ammonium (QA) was used for sanitizing/disinfecting in the three-compartment sink and also in the red buckets staff used to wipe down prep surfaces and kitchen areas. A red bucket with clear solution and a kitchen cloth was on the stainless steel surface that held items to be washed leading into the dish machine The DM said she had prepared the bucket around 10:30 AM that morning. The solution was tested with a QA strip and it indicated a zero reading. The dispenser above the three compartment sink that provided a pre-mixed QA solution was added to a clean bucket and tested. It did not react to the QA strip and indicated zero also. The QA test strips being used had an expiration date of February 2025. She said she had extra slips in the dietary office desk. She produced 2 test strip bottles for QA and 4 test strip bottles for chlorine and she said had all expired with various dates back to 2021. She said she was responsible for ensuring there are unexpired supplies in the kitchenAt 12:02 PM the DM said her one bottle of chlorine test strips she had used that morning and had reacted when used. The expiration date was torn off the bottle.At 12:30 PM the dish machine vendor was at the facility and fixed the dish machine sanitizing problem. He said the straw in the sanitizer container had been broken off at the tip and could not pump sanitizer to the machine. The dish machine was tested and it was tested at 50 ppm. He checked the QA solution at the 3 compartment sink and the QA solution container was empty. He replaced the container and the QA solution tested at 400 ppm. He said the dish machine and the 3 compartment sink sanitizing solutions were providing the correct sanitation.During an interview on 08/06/2025 at 9:10 AM the administrator said she had the CDM from another facility come about 2 weeks ago and assist the current DM with cleaning and setting up the dietary department because it was in disarray. She said she had had her come back again on 08/05/2025 after the findings on 08/04/2025. She said the deep fryer was usually cleaned after they had fried fish because it did cause a lot of the batter to fall off into the oil during the frying process. She said usually when the oil was nearing the time to be changed they would fry the fish, drain the old oil and clean the fryer and replenish with fresh oil.Review of undated facility Dietary Policy indicated the following: Cleaning and Sanitizing Equipment and Work Surfaces.sanitize all work surfaces with a double-strength sanitizing solution and with clean cloths used only for this purpose. Food Handling and Preparation.use clean, sanitized equipment and worktables.keep foods covered whenever possible unless in immediate use. Manual Ware Washing.use a 3 compartment sink.sanitize using manufacturer's recommendations for chemical sanitizer.drain and air dry. Sanitation.1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair.6. Ice which is used in connection with food or drink shall be from a sanitary source. Event ID: Facility ID: 675709 If continuation sheet Page 3 of 3