Inspection·June 16, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed, in that: Residents Affected - Few -There was an unlabeled and undated 12 oz. can of soda in the walk-in refrigerator -There was an unlabeled and undated pitcher with yellow liquid in it -There was a 5-pound open box of pancake mix in a storage bag that was not sealed -There were 34 of 56 plastic bowls on the clean rack that had a white flakey substance and/or removable brown and/or white stains -There were 20 of 81 plastic cups, on the clean rack that had brown and/or white substances in them -There were 13 of 43 clear plastic dessert dishes on the clean rack with stuck-on brown and/or white substances in them -There were 2 of 10 plastic soup bowls on the clean rack with stuck-on light brown substances in them -There were 5 of 58 small glass bowls on the clean rack with stuck-on yellow and/or white substances on them and many were wet -Of 51 plastic and ceramic saucers on the clean rack, 1 ceramic saucer had a crack in the middle and 1ceramic saucer had a sharp chip on the edge -Two plastic saucers had a stuck-on yellow substance. -The sanitizer and temperature log for the dishwasher was inaccurate -The temperature of the handwashing sink water was below the requirement - The walk-in freezer log was inaccurate -The steam table wells were not clean -The shelf directly above the food on the steam table had a brown substance the length of it -There was no thermometer or temperature log in the B-wing nutrition room freezer -Sandwiches for evening snacks were left at room temperature overnight -The juice dispenser hose and nozzle were dangling off the juice machine - The nutrition room had no thermometer or temperature log for the freezer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 2 of 5 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 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 These failures could place residents who who receive meals from the kitchen at risk for foodborne illness. Level of Harm - Minimal harm or potential for actual harm The findings included: Initial kitchen tour, observations, and interview with the DM on 06/13/23 from 10:53-11:53 AM: Residents Affected - Few There was an unlabeled and undated 12 oz. can of soda in the walk-in refrigerator. The DM stated it belonged to one of the kitchen staff members. The DM stated it was not supposed to be there. There was also a clear pitcher with manufactured markings on the side that was covered with plastic wrap, but unlabeled and undated. The pitcher had over 1 quart of a clear, yellow liquid in it. The DM stated it should not have been in there. In dry storage, there was a 5-pound open box of pancake mix in a storage bag that was not sealed. There were 34 of 56 plastic bowls in the clean rack that had a white flakey substance and/or removable brown and/or white stains. The DM was able to scrape or wipe off the substances in the bowls with his fingers. There were 20 of 81 plastic cups, also on the clean rack with the same type of brown and/or white substances in them. The DM identified the clean racks of dishes. The DM stated they should not be using them because the stuff could come off into the food and make the residents sick. The DM stated all kitchen staff was responsible for making sure the dishes were clean before use. The DM stated he did not know why or how the dirty dishes made it to the clean racks. The sanitizer and temperature log for the lo-temp dishwasher had 120 F listed for the temperatures and 50 ppm for the sanitizer for each day in June 2023. The DM checked the sanitizer twice in my presence-the first time the chem-strip read 50 ppm, and he discarded the container of chem-strips. Opening a new container of chem-strips, the reading was 100 ppm. The DM was asked what the proper reading should be, and he stated, 100 ppm. He was asked about the readings of 50 ppm documented on the log, and he stated, I think they're guessing. The DM stated it was not ok to do that (just write the same numbers). The handwashing sink was temped with this surveyor's thermometer at 103 F. The DM was asked what the temperature should be for the handwashing sink and using the facility's thermometer, the DM found the temperature to be 100 F. The DM stated the temperature of the handwashing sink water should be 110 F. The DM stated it was important to have the proper temperature of water for handwashing, otherwise, the kitchen staff's hands could not get clean enough and it could potentially make the residents sick if someone handling the food had unclean hands. The DM stated he had never watched the kitchen staff wash their hands-he did not know if they were washing for 20-30 seconds. The walk-in freezer log documented 0 degrees for each day in June 2023. Observation of the outer thermometer showed -2 F. The internal thermometer showed -5 F. The DM stated the freezer logs can't be right. The underside of the shelf directly above the food on the steam table had a thick, sticky-looking brown substance the length of it. Observation and interview of the nutrition room with the DON on 06/15/23 at 3:19 PM revealed no thermometer or temperature log for the freezer. The DON stated she was unaware of this regulation. She stated it was important to have a log for temperatures so if there was a trend or abnormal temperature, it could be tracked or possibly need a new refrigerator. An interview with LVN-A on 06/15/23 at 3:25 PM stated peanut butter and jelly and dry ham & cheese sandwiches were brought to the nurse's station in the evenings around 9:00 pm to pass out for snacks to the residents-any remaining sandwiches were left at the nurse's station at room temperature until they were picked up by the kitchen staff in the mornings at around 6:00 am. Any resident wanting a sandwich during the night would be given one of the sandwiches. LVN-A stated he usually worked the night shift and could verify this process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 3 of 5 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview with the ADM on 06/15/23 at 4:19 PM stated peanut butter and jelly and dry ham & cheese sandwiches were brought to the nurse's station in the evenings whenever kitchen staff leaves, usually around 4:00 pm-5:00 pm. The ADM stated the sandwiches were wrapped individually on a tray and left at the nurse's station for whoever might want one during the night. The ADM stated the tray was not cooled in any way. The ADM stated she has had one of the sandwiches sometimes when she stayed late around 10:00 pm or midnight. An interview with the ADM on 06/16/23 at 8:10 AM stated the facility did not have a policy for evening snacks. The ADM provided a list of residents with scheduled evening snacks-there were two names. Observations during a follow-up visit to the kitchen on 06/16/23 at 8:42 AM revealed 13 of 43 clear plastic dessert dishes on the clean rack had stuck-on brown and/or white substances in them. 2 of 10 plastic soup bowls on the clean rack had stuck-on light brown substances in them. 5 of 58 small glass bowls on the clean rack had stuck-on yellow and/or white substances on them and many were wet. Of 51 plastic and ceramic saucers, 1 ceramic saucer had a crack in the middle and 1 had a sharp chip on the edge, capable of cutting skin. Two plastic saucers had a stuck-on yellow substance. The 5 steam table wells had flaking, scaling, and floating light-yellow substances on the bottom and sides of them, some with a black dotted substance on the inside corners and sides, others with a brown substance on the inside walls. The juice dispenser tubing and nozzle was dangling down the machine and the side of the table it was on, in a pathway through the kitchen-the holder for it was missing. An interview with the DM on 06/16/23 beginning at 8:52 AM stated everyone in the kitchen was responsible for making sure the dishes were clean and dry before serving. The DM stated the steam table wells were cleaned weekly. The DM stated the steam table wells did not look clean. The DM stated the steam table wells should be shiny, like the stainless tabletops when clean. The DM stated the process for delivering evening snacks was that it was the last thing the kitchen staff did before they left around 8:00 PM - 8:30 PM. The DM stated the juice dispenser tubing and nozzle should not be hanging down because it was a hazard, people could be running into it, and the nozzle could get something on it, and when it was used again, it could make the residents sick. The DM stated the kitchen staff made 15-20 peanut butter, peanut butter and jelly, ham, and ham with cheese sandwiches, wrapped them individually, placed them on a sheet tray, then took them to the nurse's station every evening. First, the DM stated the kitchen staff took the sandwiches to the refrigerator in the nurse's station, then the DM said they take the sandwiches to the nurse's desk, and the nurses were supposed to put them in the refrigerator. The DM then stated the tray of sandwiches was left on the nurse's desk, and he did not know what the nurses did with them. The DM stated the kitchen staff picked up the tray (of sandwiches) around 5:15 AM -5:30 AM, with whatever was left on them when the kitchen staff arrived at the facility around 5:00 am. The DM stated deli meats could only be left unrefrigerated for an hour, tops. The DM stated, After an hour, deli meats start growing bacteria and it could make whoever ate them, sick. The DM stated he had provided no education to the nursing staff regarding the sandwiches needing to be refrigerated. The DM stated he had worked at the facility for 6 months. The DM stated the kitchen staff was writing the wrong numbers regarding the freezing temperatures documented on the walk-in cooler logs. The DM stated the freezing temperatures on the walk-in cooler would cause all the produce to be ruined. The DM stated he looked at the interior thermometers personally when he got to the facility but did not look at the logs even though it was his responsibility to do so. The DM stated 33 F-40 F was the range the walk-in cooler should be. The DM stated the reason logbooks were important as they were kept for the state. The DM stated, If all the temperatures documented in the logbooks were right, a lot of food would go bad. The DM stated he had not had to throw away any frozen produce from the walk-in cooler. The DM stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 4 of 5 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 675933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Treasure Hills Healthcare and Rehabilitation Cente 2204 Pease St Harlingen, TX 78550 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 the numbers should fluctuate for all the logs. The DM stated the dishwasher was a lo-heat type. Level of Harm - Minimal harm or potential for actual harm A phone interview with the RD on 06/16/23 at 1:33 PM stated, First of all, the kitchen should not be sending sandwiches for evening snacks. The evening snack should be something lighter, such as cookies or crackers. The RD stated, Anything like meats, cheese, or dairy should be refrigerated immediately. Residents Affected - Few A record review of the cleaning logs documented the steam table wells were cleaned on 06/15/23, 06/08/23, and 06/01/23. A record review of the walk-in cooler, walk-in freezer, 3-compartment sink, and the washer temperature and sanitization logs all had the same numbers in them since 2021. Except for March 2021, the monthly walk-in cooler logs documented the daily temperature to be at or below freezing (20 F-32 F). A record review of the dishwasher temperature and sanitization logs had the same numbers in them since 2021. The temperature was documented as 120 F and the sanitization was documented as 100 ppm (parts per million). Regulations require a minimum temperature for a lo-heat washer to be 120 F, and the sanitization as 50 ppm. A record review of the 3-compartment sink logs from March 2021 to the present documented on all days the same numbers; 200 ppm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675933 If continuation sheet Page 5 of 5