Health inspection·January 26, 2023

F 0812 on the floor. There were crumbs underneath the shelves and in the middle of the floor. Level of Harm - Minimal harm or potential for actual harm Observation of the walk-in freezer on 1/24/2023 at 9:10 AM - 9:45 AM revealed hard ice on the floor near the door. There were approximately 10 inches of ice on the middle shelf away from the door. Approximately 8-10 inches of ice particles hanging down from the fan located near the ceiling. Observed crumbs on the floor. Residents Affected - Many B. Observation of the walk- in refrigerator and walk-in freezer in the kitchen on 1/24/2023 at 9:10 AM - 9:45 AM revealed the following: - nectar thickened juice in the refrigerator, not in its original package without a label. -box of turkey breast and one gallon of partially opened [NAME] dressing touching the pipe located near the ceiling of the refrigerator. The pipe had black tape wrapped around it. There were approximately 6-8 inches of the tape loose and there was grime inside the loose portion of the tape. - there were 4 boxes of food stacked on top of each other with the top box touching the fan located approximately 8 inches below the ceiling of the refrigerator. The label of the boxes was not in view, unable to determine what food was in each box. When moved to view the label, two of the boxes began to fall from the top shelf of the refrigerator. -approximately 8-10 pounds of pork loin, a plastic bag of chicken in its original package, and boxes of ice cream and french toast stored on the top shelf of the freezer touching the pipe. There were approximately 4 inches of ice on the box of the french toast. The pipe had black tape wrapped around it and the black tape was loose from the pipe. There was grime on the inside of the black tape. - one partially opened pie dough and one sealed pie dough touching the fan on top of the freezer. The pie dough was located where the ice particles were hanging from the fan. - one partially opened left over ½ gallon of ice cream not dated and one partially opened gallon of ice cream not dated. - a bag of ice stored on the floor of the walk-in freezer with a tear on the bottom of the bag. C. Observation on 01/24/2023 at 9:10 AM - 9:45 AM revealed Dietary Aide B was not wearing a beard net. His beard was approximately 8-10 inches long. He was removing clean plates, pans, and silverware from the dishwasher. In an interview on 01/24/2023 at 9:35 AM Dietary Aide B stated he was required to wear a beard net when in the kitchen. He stated the beard nets were in the same bin as the hair nets. He stated before he entered the kitchen, he placed a hair net on his head but there were not any beard nets available. He stated he looked for beard nets and there was not any in the kitchen. He stated when there were not any beard nets he waited until someone had access to the storage and brought more beard nets to the kitchen. In an interview on 01/24/2023 at 9:40 Am the Dietary Manager stated she forgot to get the beard nets from the storage room. She stated she usually kept extra hair nets and beard nets in the kitchen if there was not any in the bin by the kitchen door. She stated it was her responsibility to ensure the staff had beard nets and hair nets. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676071 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 676071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groesbeck Ltc Nursing and Rehabilitation 607 Parkside Dr Groesbeck, TX 76642 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 Observation on 01/25/2023 at 7:55 AM Dietary Aide C's hair net was not completely covering her hair when she placed residents' breakfast plates on the meal tray cart. Approximately 8-10 inches of her hair was not covered from her forehead to middle of her head. In an interview on 01/25/2023 at 7:58 AM Dietary Aide C stated all her hair was expected to be covered with the hair net. She stated she did not realize most of her hair was not covered with the hair net. She stated she was in serviced on the proper use of wearing hair nets when in the kitchen many times. D. Observation in the dry storage room on 01/24/2023 at 9:10 AM - 9:45 AM revealed: - There was a case of prune juice with a date of 07/08/2022 on the box. The expired date on the cans of the prune juice was 01/05/2023. - There was a flat tray with eight loaves of Texas toast bread in the original clear bag without a label or date on the bags. On the flat tray was a date 12/20/2022. In an interview on 01/24/2023 at 9:25 AM the Dietary Manager stated all foods on the flat trays had the dates on labels located on the trays. She stated she did not know if the date was accurate. She also stated the staff was expected to place the label with the expiration date on the tray. She stated if the date was not accurate the staff was expected to change the date on the trays. She stated the date on the Texas toast bread was 12/20/2022 from the label on the tray. E. Observation on 01/25/2023 at 10:15 AM the Dietary [NAME] A was not wearing gloves. He picked up small pieces of raw chicken from the prep table and opened the top of the garbage can to dispose the raw chicken. He returned to the food prep table and began wiping the table with a wet small towel. He touched the raw chicken stored in a bowl as he was moving the bowl. Dietary [NAME] A placed oven mitts on his hands to remove the corn bread from the oven. He placed the pan of corn bread on the prep table and removed the oven mitts. When he removed the oven mitts 4 of his fingers on his right hand touched a small portion of the corn bread. After he touched the cornbread, he donned gloves without washing or sanitizing his hands. In an interview on 01/25/2023 at 10:25 AM Dietary [NAME] A stated he did not wash or sanitize his hands prior to placing the gloves on his hands. He stated he did pick up pieces of raw chicken and opened the garbage can and threw the chicken in the garbage. He stated he did not wash or sanitize his hands or put on gloves when he used the oven mitt to remove the cornbread from the oven. He stated he was required to wash his hands when they were dirty. He stated he would consider his hands dirty when he touched the raw chicken, rag and the garbage can. He stated there was a possibility that germs could transfer to residents' food and a resident could become ill if the cook did not properly sanitize hands when cooking meals for the residents. He stated he had been in serviced on hand washing and wearing gloves. In an interview on 01/26/2023 at 8:35 AM, the Dietary Manager stated the oven was expected to be cleaned immediately when staff observed it was dirty. She stated the oven was dirty on 01/24/2023 and it needed to be cleaned. She stated it was her understanding that it had been approximately 2 weeks since the oven had been cleaned. She stated there was a potential that the food being cooked in the oven could get bacteria on the food from the oven not being sanitary. She also stated with the oven not being clean there was a potential for a fire. She stated the floors in the refrigerator and freezer had not been swept for two or three days. She stated if there was any type of food on the floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676071 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 676071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groesbeck Ltc Nursing and Rehabilitation 607 Parkside Dr Groesbeck, TX 76642 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 in either the refrigerator or freezer the staff was expected to sweep it immediately. She stated with ice on the floor in the freezer there was a potential someone could fall. She stated the ice on the shelf and floor in the freezer was from condensation. She stated she did not check or have maintenance to check the fan or pipes to determine if the ice could be frozen from a possible water leak. She stated boxes of food in the refrigerator and freezer were not to be stacked on top of each other. She stated there needed to be space between boxes for air circulation. She stated stacking boxes on top of each other was a hazard especially if the boxes were on the top shelf. She stated all food including left over food was expected to be labeled and dated. She stated all expired food and juices were to be disposed. She stated any food in the refrigerator or freezer was not to be stored next to the fan or pipe. She stated this was not acceptable. She stated all staff entering the kitchen was expected to wear hair nets and beard nets. She stated the hair net was to cover all the staff's hair and if it did not there was a potential hair could fall into the food, plates, or anything the residents would be using for their meals. She stated it was her responsibility to ensure the staff had adequate amount of beard guards and hair nets. She stated hair could fall from a man's beard into resident food or plates. She stated all staff was to follow the hand sanitizing protocol. She also stated she had not reported anything to Maintenance about the ice on the freezer floor or other areas in the freezer. In an interview on 01/26/2023 at 8:20 AM the Maintenance Director stated he asked if there were any maintenance issues during department head morning meetings. He stated he took a small notebook into the morning meeting and if there were any maintenance issues, he would write it in the notebook and take care of any problems. He stated the Dietary Manager was in these meetings. He stated he was not aware of ice on the floor or shelves in the freezer. He stated if there were icicles on the fan and ice on the shelves there was a possibility it was from condensation or it might be from something else. He stated if there were any maintenance issues that needed to be taken care of after the morning meeting the staff would verbally report it to him or text him. He stated he was not aware of any ice issues in the freezer of the kitchen. In an interview on 01/26/2023 at 11:00 AM the Dietary Manager stated all dietary staff was to wash hands before they placed gloves on hands and between tasks especially when touching raw chicken and the garbage can. She stated this was cross contamination and a resident had the potential of becoming ill with some type of stomach problems and possibly a resident may need hospitalization. She stated if residents had anything that was out of date the resident could become ill with food poisoning. She stated it was her responsibility to monitor the kitchen and the dietary staff. In an interview on 1/26/2023 at 11:35 AM the Administrator stated the oven was required to be cleaned whenever it was dirty. She stated if the oven was not clean there was a potential for residents to become ill from the bacteria in the oven. She stated there was also a possibility of an oven fire. She stated all floors needed to be cleaned whenever there was any type of food or dirt on the floors including refrigerator and freezer. She stated if there was ice on the floor in the freezer this could be a hazard for someone to fall. She stated the ice in the freezer was from condensation. She stated there was a possibility there was a leak, however, she did not believe there was any type of leaks, and the ice was from condensation. She stated if residents ate undated left-over foods there was a possibility for the resident to become ill with food poisoning or any type of stomach issues. She stated all dietary staff was required to wear a hair net and for males with beards a beard net. She stated if hair was not completely covered and if males was not wearing a beard net, hair could fall into residents' food. She stated a resident could become ill. She stated boxes or containers of food were not appropriate to store next to the fan or pipes in the refrigerator or freezer. She stated staff was to wash hands in the kitchen after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676071 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 676071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groesbeck Ltc Nursing and Rehabilitation 607 Parkside Dr Groesbeck, TX 76642 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 touching anything that was contaminated. She stated it was the Dietary Manager's responsibility for monitoring the kitchen and the dietary staff. Review of Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices Policy dated October 2017 revealed the following: Residents Affected - Many - Employees must wash their hands: after handling raw meat, poultry, or fish and when switching between working with raw food and working with ready-to-eat food. -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. -Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. -Hair nets or caps and/ or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Review of Food Receiving and Storage Policy dated October 2017 revealed food services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. Partially eaten food may not be kept in the refrigerator. Review of Refrigerators and Freezers Policy dated December 2014 revealed the following - This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. -Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired past perish dates. -Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. -Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of Sanitation Policy dated October 2008 revealed the following: All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/ or chemical sanitizing solution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676071 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 676071 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Groesbeck Ltc Nursing and Rehabilitation 607 Parkside Dr Groesbeck, TX 76642 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 For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: Equipment will be disassembled as necessary to allow access of the detergent/ solution to all parts. Removable components will be scraped to remove food particles accumulation and washed according to manual or dishwashing procedures. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676071 If continuation sheet Page 6 of 6