Health inspection·February 7, 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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Residents #27) reviewed for care plans. 1. The facility failed to support Resident #27's needs for post-traumatic stress disorder (PTSD). These failures could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #27's admission record, dated 02/05/2024, revealed an admission date of 09/15/2023 with diagnoses which included PTSD. A record review of Resident #27's entry MDS assessment dated [DATE] revealed Resident #27 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of 15 which indicated moderate cognitive impairment. Further review of Resident #27's MDS revealed, Psychiatric / Mood Disorder: Post Traumatic Stress Disorder .Anxiety Disorder. A record review of Resident #27's physician's orders summary dated 02/06/2024 revealed Resident #27 was ordered sertraline 25mg daily for anxiety related to anxiety disorder. A record review of Resident #27's care plan dated 02/06/2024 revealed no interventions and / or support for Resident #27's diagnosed PTSD. During an interview on 02/05/2024 at 10:20 AM Resident #27 declined to be interviewed for his diagnosed PTSD and redirected the interview. During an interview on 02/06/2024 at 12:07 PM, the DON stated a record review of Resident #27's MDS revealed Resident #27 was diagnosed with PTSD and a record review of Resident #27's care plan revealed no interventions for PTSD. The DON stated Resident #27's diagnosis of PTSD was from a previous assessment and would need to be researched. A record review of the facility's undated Comprehensive Care Planning policy revealed, The facility Page 1 of 14 675929 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0656 Level of Harm - Minimal harm or potential for actual harm will develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights that includes measurable objectives and time frames to meet a residence medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . when developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set to assess the residents clinical condition, cognitive and functional status, and use of services Residents Affected - Few 675929 Page 2 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility's interdisciplinary team failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 (Resident #12) residents reviewed for revised care plans. The facility failed to revise Resident #12's care plan to remove conflicting plans for Resident #12's diet texture needs. This failure could place residents at risk for harm with conflicting care plans. The findings included: A record review of Resident #12's admission record, dated 02/05/2024, revealed an admission date of 08/19/2023 with diagnoses which included dysphagia following cerebral infarction (difficulty swallowing after a stroke). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old female admitted for long term care and could not participate in a BIMS score assessment. A record review of Resident #12's physician's orders summary dated 02/06/2024 revealed on 11/29/2023 Resident #12 was ordered a diet texture upgrade with regular diet / mechanical soft texture / regular-thin consistency. A record review of Resident #12's care plan dated 02/06/2024 revealed Resident #12 had a swallowing problem related to spillage of food and fluids from her mouth while eating and pocketing food with meals, Interventions: .LIQUIDS: Nectar thickened liquids Date Initiated: 08/21/2019 . Pureed diet with Nectar thickened liquids Date Initiated: 11/14/2017 Revision on: 11/11/2022 During an interview on 02/06/2024 at 12:07 PM, the DON stated Resident #12 was ordered a regular mechanical soft diet with thin liquids and a record review of Resident #12's current care plan revealed conflicting care interventions for Resident #12's diet textures. The DON stated the care plan should have been revised to reflect Resident #12's upgraded diet texture from pureed and thickened liquids to mechanical soft foods with thin liquids. The DON stated the risk for residents with conflicting care plans could be inconsistent care. A record review of the facility's undated Comprehensive Care Planning policy revealed, The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the residents rights that includes measurable objectives and time frames to meet a residence medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . when developing the comprehensive care plan, facility staff will, at a minimum, use the minimum data set to assess the residents clinical condition, cognitive and functional status, and use of services . the residents care plan will be reviewed after each admission, quarterly, annual, and/or significant change . and revised based on changing goals, preferences, needs of the resident, and in response to current interventions 675929 Page 3 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as was possible for 1 (Resident #14) of 6 smokers. Resident #14 had a personal lighter that was in her purse. This could affect all residents and could result in a fire. The findings were: Record review of Resident #14's admission record dated 2/7/2024 revealed she was admitted on [DATE], re-admitted on [DATE], and she was her own responsible party. Record review of Resident #14's admission record revealed her diagnoses were dementia without behaviors, major depressive disorder, anxiety, protein calorie malnutrition, chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and pain. Record review of Resident #14's Quarterly MDS assessment dated [DATE] revealed her BIMS score was 11/15 (moderately impaired), she had no behaviors, she used a wheelchair to mobilize, she was independent for hygiene, toileting, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #14's Care plan dated 11/23/2023 revealed she was a smoker. Interventions were to perform smoking assessments according to facility policy, explain/show where designated smoking areas were and smoking times, monitor as needed when smoking to assure resident safety, and keep smoking material at nurse's station. Record review of Resident #14's Safe Smoking assessment dated [DATE] revealed summary: this resident requires direct supervision while smoking, all smoking materials will be kept at the nurse's station, and the care plan up to date or updated. In an interview on 2/04/2024 at 3:18 PM with Resident #14 , she stated she kept her lighter in her purse, all staff knew she had a lighter. Resident #14 stated she knew she was not supposed to have a lighter because of fire safety. Resident #14 stated the lighter the case was in was a gift from her late husband. Interview on 2/04/2024 at 4:42 PM with Administrator and DON revealed that they were not aware that Resident # 14 had her own lighter. The Administrator and the DON stated the residents were not allowed to have their own lighters and all were supervised by staff that had the lighters. The Administrator stated he did confiscate the lighter from Residents #14, reviewed the smoking policy with her. The Administrator stated he in-serviced the staff on the smoking policy and how they were to supervise residents during smoke breaks. Record review of the Smoking policy dated 4/26/2022 revealed Smoking policies must be formulated and adopted by the facility. The policies must comply with all applicable codes, regulations, and standard, including local ordinances. The facility is responsible for informing residents, Staff, visitors, another affected parties of smoking policies through distribution and/or posting. The facility 675929 Page 4 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0689 is responsible for enforcement of smoking policies which must include at least the following provisions: 1 .lighters or other ignitions sources for smoking are not permitted to be kept or stored in a resident's room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 675929 Page 5 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities which involved 1 of 6 residents (Resident #21) observed during medication administration reviewed for medication errors . Residents Affected - Some 1. LVN C failed to administer Resident #21's losartan and fluticasone nasal spray at the prescribed times. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: A record review of Resident #21's admission record, dated 02/06/2024, revealed an admission date of 09/08/2023 with diagnoses which included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A record review of Resident #21's admission MDS assessment, dated 11/22/2023, revealed Resident #21 was a [AGE] year-old female admitted to the facility for short term care and assessed with a BIMS score of 12 out of a possible 15, which moderate cognitive impairment. A record review of Resident #21's care plan, dated 02/06/2024, revealed resident has a diagnosis of chronic obstructive pulmonary disease related to smoking . give aerosol or bronchodilators (airway medications) as ordered . resident has hypertension (high blood pressure) . give anti-hypertensive medications as ordered A record review of Resident #21's physicians' orders, dated 02/06/2024, revealed Resident #21 was to receive losartan (a medication to lower blood pressure) 50mg by mouth one time a day, in the evening, related to essential hypertension. Further review revealed Resident #21 was to receive fluticasone nasal spray once a day at 08:00 PM for allergies. During an observation on 02/06/2024 at 09:24 AM revealed LVN C Prepared medications for Resident #21 which included 1 pill of losartan 50mg and 1 spray bottle of fluticasone and entered Resident #21's room and administered the losartan and the fluticasone spray at 09:33 AM. During an interview on 02/06/2024 at 10:02 AM LVN C stated upon review of the medication administration record she had administered Resident #21's losartan and fluticasone at the wrong time. LVN C stated she made a mistake and recognized the medications should have been administered in the evening. LVN C stated she had made a medication administration error and would assess Resident #21, report to the physician, and report the errors to the DON. During an interview on 02/06/2024 at 12:07 PM, the DON stated the training and expectations were for nursing staff to administer medications on time as prescribed. If it was not possible then for staff to immediately report to their supervisors, which included herself (the DON), and intervention 675929 Page 6 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some measures could be employed to ensure residents received their medications as prescribed. The DON stated the risk to residents who did not receive their medications as prescribed could be under dosing and or overdosing. During an interview on 02/06/2024 at 12:28 PM, the Administrator stated the DON had reported Resident #21 received some of their medications too early and could place residents at risk for not receiving their medications as prescribed. A record review of the facility's Medication Administration Procedures dated 2003, revealed, .the 10 rights of medication (administration) should always be adhered to: 1. Right patient; 2. Right medication; 3. Right dose; 4. Right route; 5. Right time; 6. Right patient education; 7. Right documentation; 8. Right to refuse; 9. Right assessment; 10. Right evaluation 675929 Page 7 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors, for 1 of 7 residents (Residents #6) reviewed for significant medication errors. Residents Affected - Some 1. The facility failed to administer to Resident #6, lisinopril (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. 2. The facility failed to administer to Resident #6, hydrochlorothiazide (a medication which lowers blood pressure) according to the physician's orders. Resident #6 was administered lisinopril while Resident #6 had low blood pressure. These failures could place residents at risk for not receiving the therapeutic effects of the medications prescribed. The findings included: A record review of Resident #6's admission record, dated 02/04/2024, revealed an admission date of 12/02/2021 with diagnoses which included hypertension (high blood pressure). A record review of Resident #6's admission MDS assessment, dated 12/22/2023, revealed Resident #6 was a [AGE] year-old female admitted to the facility for long term care and assessed with a BIMS score of 11 out of a possible 15, which indicated moderate cognitive impairment. A record review of Resident #6's care plan, dated 02/06/2024, revealed resident has a diagnosis of chronic obstructive pulmonary disease related to smoking . give aerosol or bronchodilators (airway medications) as ordered . resident has hypertension (high blood pressure) . give anti-hypertensive medications as ordered A record review of Resident #6's physicians' orders, dated 02/06/2024, revealed Resident #6 was to receive lisinopril 10mg (a medication to lower blood pressure) by mouth one time a day, in the morning, related to hypertension and was not to be given if Resident #6 was experiencing low blood pressure, hold if SBP (systolic blood pressure) is less than 110 and/or DBP (diastole blood pressure) is less than 60 or pulse is less than 60. A record review of Resident #6's February's medication administration record revealed Resident #6 was administered lisinopril 10mg on 02/03/2024 while her blood pressure was lower than the 110 prescribed by the physician, 99/62 BP; 62 pulse by LVN B. 2. A record review of Resident #6's physicians' orders, dated 02/06/2024, revealed Resident #6 was to receive hydrochlorothiazide 25mg (a medication to lower blood pressure) by mouth one time a day, in 675929 Page 8 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the morning, related to hypertension and was not to be given if Resident #6 was experiencing low blood pressure, hold if SBP (systolic blood pressure) is less than 110 and/or DBP (diastole blood pressure) is less than 60 or pulse is less than 60. A record review of Resident #6's February's medication administration record revealed Resident #6 was administered hydrochlorothiazide 25mg on 02/03/2024 while her blood pressure was lower than the 110 prescribed by the physician, 99/62 BP; 62 pulse by LVN B. During an interview on 02/06/2024 at 11:50 AM LVN B stated she could not recall the details of the medication administration on the morning of 02/03/2024. LVN B stated on 02/03/2024 she administered medications and documented on the resident's medication administration record. LVN B stated she reviewed the medication administration record for 02/03/2024 for Resident #6 and recognized she documented low blood pressure for Resident #6 and administered lisinopril and hydrochlorothiazide, both drugs which lower blood pressure while Resident #6 was assessed with low blood pressure 99/62, 60 pulse. LVN B stated she should have not administered the medications. During an interview on 02/06/2024 at 12:07 PM, the DON stated the training and expectations were for nursing staff to administer medications on time as prescribed. If it was not possible then for staff to immediately report to their supervisors, which included herself (the DON), and intervention measures could be employed to ensure residents received their medications as prescribed. The DON stated the risk to residents who did not receive their medications as prescribed could be under dosing and or overdosing. The DON stated the risk for Resident #6 was lowered blood pressure and dizziness. During an interview on 02/06/2024 at 12:28 PM, the Administrator stated the DON had reported Resident #6 received some of their medications too early and could place residents at risk for not receiving their medications as prescribed. A record review of the facility's Medication Administration Procedures dated 2003, revealed, .the 10 rights of medication (administration) should always be adhered to: 1. Right patient; 2. Right medication; 3. Right dose; 4. Right route; 5. Right time; 6. Right patient education; 7. Right documentation; 8. Right to refuse; 9. Right assessment; 10. Right evaluation 675929 Page 9 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 medication cart, reviewed for security. The facility failed to attend and secure the short-hall medication cart. This failure could place residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications. The findings included: During an observation on 02/04/2024 at 08:56 AM, revealed the facility's short-hall medication cart was stationed by the nurse station at the beginning of the facility's 2 halls, the short-hall and the long-hall. Further observation revealed the medication cart unattended, and unlocked. The medication cart was observed to have the lock button unengaged and unlocked. Observations from 02/04/2024 from 08:56 to 09:09 AM revealed LVN B was attending residents at the end of the long-hall and residents were ambulating nearby the unattended unsecured medication cart. RN A and LVN H passed by the unattended unsecured medication cart without recognizing the medication cart was unlocked. During an observation and interview on 02/04/2024 at 09:10 LVN H was alerted by the state surveyor that the medication cart was unattended and unlocked. LVN H approached the medication cart and locked the cart. LVN H stated the medication cart was designated for the short-hall and was supposed to be locked. LVN H stated the cart was assigned to LVN B who was attending both halls and was currently attending residents down the long-hall. During an interview on 02/04/2024 at 09:15 AM LVN B stated she was the facility's nurse and the cart she had charge of was the short-hall medication cart. LVN B received a report from the state surveyor that the medication cart was left unlocked and unattended while LVN B was observed down the hall attending to an unidentified resident. LVN B stated she had gone down the hall to attend to a resident and she had left the medication cart unattended and unlocked. LVN B stated she should have locked the cart and did not. During an interview on 02/06/2024 at 12:07 PM, the DON stated the training and expectations were for nursing staff to secure the medication carts when the cart would not be in use. The DON stated the risk to residents who did not have their medications secured would be for their medications to be mishandled. During an interview on 02/06/2024 at 12:28 PM, the Administrator stated the DON had reported LVN B had left the short-hall medication cart unattended and unsecured. The Administrator stated the facility's expectation was for the medication carts to be locked whenever the medication cart was not attended and or not in use. A record review of the facility's Medication Administration Procedures dated 2003, revealed, . After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured 675929 Page 10 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

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 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 1 of 1 kitchen. Residents Affected - Some 1. Cut onions, cut lettuce, and parmesan cheese were in zip lock bags and did not have a used by date, in the refrigerator. 2. The dish machine temperature/chemical log for February 2024 was missing. 3. The DM did not write on the substitute log the meal for Saturday, 2/3/2024. 4. The facility prepared and stored 9 peanut butter and jelly sandwiches in the resident's snack pantry refrigerator without any indicators to identify when the sandwiches were prepared or when the sandwiches were to be thrown out for food safety. This could affect residents and could result in residents not getting fresh foods, dishes that are not sanitized and cause harm. The Findings were: 1. In an observation on 2/04/2024 at 9:40 AM in the kitchen with [NAME] F in Refrigerator #2, there were cut onions in a zip lock bag that had an open date of 1/31/2024 and no use by date. There was also cut lettuce in a zip lock bag that had an open date of 1/27/2024 and had no use by date. In Refrigerator #1 there was a zip lock bag of parmesan cheese with an open date of 10/3/2023 and had no use by date. In an interview on 2/04/2024 at 9:45 AM with [NAME] F, she stated the cut food items in the zip lock bags were to have a use by date for 7 days. 2. In an observation on 2/04/2024 at 9:20 AM in the kitchen, the dishwasher area had a temperature/chemical log for January 2024 that was filled out. There was no February 2024 temperature/chemical log for the dish machine. The temperature/chemical for the dish machine was correct on Sunday, 2/4/2024. In an interview on 2/04/2024 at 9:20 AM with Dietary Aide G, he stated he had not done the dish machine temperature/chemical log when he worked due to no temperature/chemical log for February 2024. Dietary Aide G stated he was not sure if he reported that the temperature/chemical log for February 2024 was missing. In an interview on 2/06/2024 at 10:52 AM with [NAME] F, she stated she did not know about the dish machine/Chemical log. [NAME] F stated they were to keep a chemical log daily to make sure the residents don't get sick. In an interview on 2/06/2024 at 10:38 AM with DM, she stated she forgot to get a temperature/chemical log and place it on the dish machine. She stated she was in the kitchen Friday, Saturday, and Sunday and forgot to put the temperature/chemical log for February 2024 out for staff to use. 675929 Page 11 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0812 Record review of Temperature/Chemical log for February 2024 was filled out 2/6/2024. Level of Harm - Minimal harm or potential for actual harm 3. In an observation of the kitchen revealed, there was a menu substitutions log posted, it had no substitutions for 2/3/2024 on the list. Residents Affected - Some Record review on 2/3/2024 for Menu-Lunch meal was shake n bake pork chop, black eyed peas, sauteed cabbage, cornbread, and lemon buttermilk cobbler. The substitute lunch meal for 2/3/2024 was peanut butter and jelly sandwich, Frito chips, and apricots with cream. In an interview on 2/05/2024 at 11:08 AM with DM, she stated the food items in the refrigerator should have a use by date and she stated she called the dietitian but forgot to log it in the Menu substitution log. The state surveyor asked the DM for related policies. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (A) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of FOOD CODE - Commercially prepared food (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of policy food Storage and Supplies (no date) revealed all facility storage will be maintained in an orderly manner that preserves the condition of food. and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin, and insects. 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it, so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still good quality. Record review of Temperature/Chemical log (no date) 1. Dietary Services Manager will be the person responsible for making sure the Temperature/Chemical log is completed daily. 675929 Page 12 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. During an observation and interview on 02/06/2024 at 07:31 PM revealed CNA E demonstrated the residents pantry refrigerator where residents evening snacks were stored. The refrigerator revealed 9 peanut butter and jelly sandwiches individually stored in clear plastic bags. Further observation revealed the sandwiches did not have any indicators, labels, or dates to indicate when the sandwiches were made or when the sandwiches should not be served to residents to prevent food borne illnesses. CNA E stated the sandwiches should have had a date when the sandwiches were made, and the sandwiches would be safe to serve for 2 days after the date they were made. CNA E stated the sandwiches could not be served since the sandwiches could not be determined to be safe. During an interview on 02/06/2024 at 07:40 PM [NAME] D stated the sandwiches would not be served and thrown out since the food safety of the sandwiches could not be certain. [NAME] D stated the sandwiches should have been labeled with the date the sandwiches were made and could be safe to serve for 2 days while the sandwiches were kept cold in the refrigerator. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-401.11, revealed, On-premises preparation Prepare and hold cold 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 675929 Page 13 of 14 675929 02/07/2024 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen. Residents Affected - Some In the kitchen 1 (left side) of the 2 ovens on the range were not fully functional. This could affect all residents that eat meals from the kitchen and could result in residents not getting warm food cooked in the oven. The findings were: In an observation and interview on 2/04/2024 at 09:40 AM [NAME] F stated, the oven worked off and on and sometimes would not fully cook the meal. [NAME] F stated she was not sure how long. In an interview with Resident #14 stated she had a peanut butter and jelly sandwich, chips, and dessert on Saturday (2/3/2024). She stated she was told the oven did not work by the staff. In an interview on 2/04/2024 at 4:46 PM the Dietary Manager (DM) stated, the left oven was not working well and would go off and on. The DM stated Friday it was working well and then on Saturday it did not work well. She stated the menu was substituted and she had asked the warranty company to come and fix the oven. The DM stated she did notify the Maintenance Supervisor and the Administrator that the oven was not working. In an interview on 2/6/2024 at 2:51 PM with the Maintenance Supervisor, he stated he did receive a call from the Kitchen and the Administrator about the stove not working. The Maintenance Supervisor stated the oven range had been working off and on, since the beginning of 2023. The Maintenance Supervisor stated he went to the facility to check on the stove and called the warranty company to come and fix the oven range. The Maintenance Supervisor could only find work orders for 1/13/2023, 1/27/2023, and 2/6/2024. On 2/6/2024 work order the warranty representative came out to look at oven range on 2/5/2024. The Maintenance Supervisor stated he would find the other times the warranty representative came out to fix the oven range. The state surveyor exited before the Maintenance Supervisor could find the related work orders. In an interview on 2/6/2024 at 5:36 PM with the Administrator, he stated he was aware of the stove not working on Saturday and asked his staff to call the warranty company for the oven range and fix it. The Administrator confirmed the warranty company was called and they arrived to fix the stove on 2/5/2024, after the state surveyor entrance. The Administrator was not sure when the oven range would be fixed and was waiting for his corporate company and the warranty service technician to come out and fix the oven on the range in the kitchen. no policy 675929 Page 14 of 14