Inspection·March 21, 2024

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved the nutritive value, flavor, texture, and appearance for one (Lunch 03/19/24) of one meal observed for pureed food. Residents Affected - Few Dietary Manager failed to prepare pureed bread with jelly/peanut butter for Resident #6 on 03/19/24 by following recipe in order to maintain the appropriate texture and nutritive value. This failure could place residents at risk of decline in nutrition status, loss of appetite and decreased intake placing them at risk for the potential of aspiration and of unplanned weight loss. Findings included: Observation on 03/19/24 at 11:38 AM with Dietary Manager revealed she took the pureed bread out of refrigerator with spoonful of peanut butter and jelly on top of it. The Dietary Manger mixed the peanut butter and jelly into pureed bread with a spoon. Dietary [NAME] B put the pureed bread after Dietary Manger mixed it into the microwave to warm it up for 20 seconds. The Dietary Manager took the pureed bread with peanut butter and jelly out of the microwave. The pureed bread texture was watery on the edges. The Dietary Manager mixed the pureed bread after it came out of microwave with spoon. She took gloves off, did not wash her hands and put plastic over the cup. She put it on Resident #6's lunch tray. Interview on 03/19/24 at 11:45 AM with the Dietary Manager revealed she was not aware warming pureed food in the microwave could affect the food. She stated this weekend Resident #6 started requesting peanut butter and jelly with her pureed bread so it tasted better for her. She stated she made the pureed bread adding milk per the recipe. She stated she did mix the peanut butter/jelly with a spoon. She stated the consistency for pureed should be mashed potatoes consistency. She was not aware she had a recipe to follow for adding peanut butter/jelly to pureed bread. She stated she did use the food processor to make the pureed food. Record Review of Resident #6's physician orders dated 03/21/24 reflected order date of 03/01/24 of Resident #6 on pureed texture with honey consistency. Observation on 03/19/24 at 11:49 AM revealed Resident #6 was given her food tray including pureed bread and was assisted with feeding by staff. Interview on 03/19/24 at 12:32 PM with Dietary Manager revealed she did find a pureed peanut butter and jelly sandwich recipe and provided it to the surveyor. Interview on 03/21/24 at 12:39 PM with Consultant Dietitian revealed she came to facility twice monthly since the facility reopened with residents. She stated she expected the Dietary Manger to follow a recipe when adding peanut butter and jelly to pureed bread. She stated facility staff needed to follow a recipe for peanut butter and jelly and it would tell them how to mix it. She stated it was important to follow the pureed recipe for nutritional content. She stated the texture of pureed was to be smooth with no lumps. She stated microwaving food could affect the texture of the pureed food. Review of Recipe for Pureed Peanut Butter and Jelly Sandwich Half printed 03/19/24 at 1:25 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675856 If continuation sheet Page 2 of 6 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 675856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273 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 0804 Level of Harm - Minimal harm or potential for actual harm reflected one serving of peanut butter and jelly sandwich half and milk 2%. It reflected to place prepared recipe portion along with ½ recommended liquid into a blender or food processor. Blend until smooth, adding liquid/thickener as need to obtain desired consistency. There should be no lumps or particles. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675856 If continuation sheet Page 3 of 6 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 675856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273 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 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 review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator and freezer items were dated, labeled, and sealed. 2. The facility failed to ensure Dietary Manager wore an effective hair restraint and performed hand hygiene during lunch meal preparation on 03/19/24. 3. The facility failed to ensure kitchen trash cans with food debris were covered. 4. The facility failed to ensure fryer was cleaned after use. 5. The facility failed to ensure 3-compartment sink water temperature logs were documented and monitored to ensure minimum water temperature log for wash and rinse sink. These failures could place residents at risk for food contamination and food-borne illness. Findings included: 1. Observations of 1 of 2 freezers revealed the following on 03/19/24 during initial tour: - At 9:27 AM revealed an undated and vanilla ice cream in bowl with plastic covering the bowl. Interview with Dietary Manager revealed the food item was vanilla ice cream and was for one of the residents to have with for their lunch today. She stated she forgot to put a date or label on it when she put it in the freezer earlier this morning. - At 9:28 AM revealed an unsealed gallon size plastic zip bag dated 03/18/24 of tater tots. Interview with Dietary Manager revealed she would put it in 2 gallon bag so the tater tots bag can close properly. She stated it should have been sealed. - At 9:29 AM a plastic zip bag dated 2/1/24 of four celery and a plastic zip bag dated 2/1/24 of mixed vegetables not sealed in plastic bags. Observation on 03/19/24 at 9:30 AM of 1 of 2 refrigerators revealed a plastic bag dated 03/11/24 of bacon slices was not sealed. Interview on 03/19/24 at 9:33 AM with Dietary Manager revealed the items in the refrigerator and freezer should be labeled and dated when opened. She stated the refrigerator and freezer items should be sealed properly. Review of facility's dietary services Food Storage and Supplies dated 2012 reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food .4. Open packages of food are stored in closed containers with covers or in sealed bags, and dated as to when opened .9 .Perishable items that are refrigerated are dated once opened and used with 7 days, but nonperishable items that are refrigerated once opened . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675856 If continuation sheet Page 4 of 6 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 675856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273 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 2. Observations on 03/19/24 from 11:25 AM to 11:38 AM with Dietary Manager revealed her hair restraint was not covering about 0.5 inch hair above and near both of her ears along with exposing 1 inch of back of hair below the hair restraint while she pureed green beans and temped lunch food items with thermometer prior to food being served. Observation on 03/19/24 at 11:39 AM revealed the Dietary Manager mixed the pureed bread with a spoon after it came out of microwave. Dietary Manager took both of her gloves off, did not wash hands and put plastic over the pureed bread placing it own the food tray for Resident #6. She started plating food for residents' lunch. Interview on 03/19/24 at 11:45 AM with Dietary Manager revealed her gloves were not soiled when she took her gloves off. She stated she should have washed her hands hands after she took off her gloves for infection control purposes. She stated she was not aware her hair restraint was not covering her hair completely. She stated she was aware the hair restraint must cover all hair. She stated not washing her hands could place residents at risk for infections. She stated not wearing a proper hair restraint could place food at risk for being contaminated and getting hair in food. Review of facility's dietary services policy Hand Washing dated 2012 reflected We will ensure proper hand washing procedures are utilized. 3. Observation on 03/20/24 at 1:16 PM revealed cookie sheet covering the fryer and with cookie sheet removed. The fryer had dark brown grease with food particles floating on top with grease and food particles in top front of fryer. Interview on 03/20/24 at 1:17 PM with Dietary Manager revealed looking at the menu, it was last used on Monday night and should have been cleaned after use. She stated the grease is changed weekly. Review of facility's dietary services Equipment Sanitation dated 2012 reflected We will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. 4. Observation on 03/20/24 at 1:18 PM revealed one kitchen trash can in the dish machine area, the lid off of the trash can; about 6 inches exposing food particles and leftovers; it was about ¾ full. At 1:19 PM revealed one kitchen trash can in food preparation area about ½ full with food particles and debris. Interview on 03/20/24 at 1:20 PM with Dietary Manager revealed the kitchen trash can lids were not completely covering the kitchen trash cans because if they are covered then it makes it difficult to throw things away from without touching the lid. She stated they have to move the kitchen trash can lids off to dispose of trash which would contaminate their hands. Review of facility's dietary service policy Waste Control and Disposal dated 2012 reflected Waste Control and Disposal will be taken care of in a sanitary manner. Procedure: .2. Trash cans must be covered at all times, except during use. 5. Observation on 03/20/24 at 1:22 PM revealed the 3-compartment log for March 2024 posted on the wall had blanks for log for water temperatures for wash and rinse. Observation on 03/20/24 at 1:23 PM revealed a sign above the 3-compartment sink for wash sink (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675856 If continuation sheet Page 5 of 6 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 675856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whitesboro Health and Rehabilitation Center 1204 Sherman Dr Whitesboro, TX 76273 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 (first sink on right) at 110 degrees F and rinse sink (2nd sink on right) 120 degrees F. Level of Harm - Minimal harm or potential for actual harm Interview on 03/20/24 at 1:25 PM with Dietary Manager she stated she only had to do the sanitizing test strips for 3-compartment sink and did not need to check water temperatures for 3-compartment sink. She stated as long as sanitizer ppm were within appropriate levels. She stated the Maintenance Supervisor checked the water temperatures in the kitchen. She stated she used the 3-compartment sink after breakfast and lunch. Residents Affected - Many Interview on 03/20/24 at 1:27 PM with Dietary [NAME] B revealed he used the 3-compartment sink in the evening after dinner and only checked the sanitizer sink. He did not check the water temperatures for the 3-compartment sink. Interview on 03/20/24 at 1:44 PM with Maintenance Supervisor revealed he did water temperatures in kitchen weekly but did not document them or put in water temp log. He stated he did have to run hot water for a fe to get the temperature up. He stated you have to run the dish machine about 6 times when it had not been in use to get it to 120 temperature. He stated the hot water heater was the same one connected to the resident hall which was not occupied by residents at this time due to the low census so it took longer to get water temperatures in kitchen up to proper temperature. Record Review of water temperature log for 3-compartment sink for January to March 2024 revealed no water temperatures for wash/rinse for 3-compartment sink. Record Review of Maintenance Supervisor's log revealed no kitchen log for water temperatures in the kitchen. Interview on 03/21/24 at 12:39 PM with Consultant Dietitian revealed the dietary staff changing gloves and not washing hands were an infection control issue and can cause cross contamination. She stated dietary staff not wearing effective hair restraints covering all hair could place food at risk of hair getting it in and cross contamination. She stated refrigerator and freezer items if removed from original container need to be labeled and dated when opened. She stated the refrigerator and freezer items should be sealed properly to prevent freezer burn and can impact the food integrity. Follow-up interview on 03/22/24 at 11:23 AM with Consultant Dietitian revealed she wanted to clarify the 3-compartment sink hot water temperatures should be monitored along with sanitizer levels. Review of the FDA US Food Code 2022 reflected the following: -under section 2-3 Personal Cleanliness 2-301.11 Clean Condition Food Employees shall keep their hands and exposed portions of their arms clean. -under section 3-602.11 Food Labels 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . -under section 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675856 If continuation sheet Page 6 of 6