Health inspection·May 22, 2025

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, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. Residents Affected - Few The facility failed to ensure food safety on 05/20/2025 by not temping hot foods before service, consistently monitoring, and discarding expired food, maintaining unsanitary kitchen equipment and storage areas when food items were not labeled and/or dated and Drawers where the serving utensils were stored were dirty. These failures could place residents who received meals from the main kitchen at risk for foodborne illness. Findings included: Observation on 5/20/2025 at 8:45 AM of the walk-in refrigerator reflected the following: Hot dogs in a sealed bag were dated 4-18 with no discard date. Cheese in a sealed bag that was not in the original package was dated 5-16 with no discard date. Lunch meat in a sealed bag that was dated May 16 with no discard date. Ketchup in a plastic container that was dated 5-19-25 with no discard date. Mechanical soft breakfast sausage that was dated 5/20 with no discard date. Observation on 5/20/2025 at 8:53 AM of the Pantry reflected the following: (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 676071 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 05/22/2025 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)