Health inspection·May 19, 2022

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the clean colanders and cutting board. She changed gloves without washing her hands. She used gloved hands to transfer salad from the large bowl into 2 orange bowls and a Styrofoam plate. She placed the bowls and plate into refrigerator. She went to dry storage, gathered items, and went to baking station. Still wearing same gloves, she removed wrapping from a block of cream cheese and placed it on the food scale. She picked up the recipe book with both gloved hands and looked at recipe. She took the block of cream cheese from food scale and placed it in a large bowl. She picked up the recipe book again. She said she was making (chilled) blueberry cheesecake pies. The 11 baked pie crusts were observed uncovered on a 3-tier cart during this 1 1/2-hour observation period. The pie crusts were on the bottom 2 shelves. The top shelf of the cart was used to transport various things around the kitchen. Cook D got a wet cleaning rag from sanitizer bucket, wiped a work surface, picked up a food thermometer and wiped the stem with same rag and put it away. She donned gloves without washing her hands and transferred fried shrimp from fryer basket and placed in a lined pan. She doffed the gloves. DA C went to the dishwasher room and got clean measuring cups, then went into dry storage and got a bag of powdered sugar and placed them at the baking station. She removed her gloves and used scissors to cut the top of the plastic bag containing whipped cream. She squeezed whipped cream into a measuring cup and transferred it into the large bowl. A white glob was noticed in the whipped cream. She fished it out with a fork and said it was the lid off the whipped cream container. DM reminded DA C she did not put on gloves. DA C donned gloves without washing her hands. She wiped spilled powdered sugar from the baking station and the top of a 3-tiered cart with a rag. She washed her hands and donned gloves. While transferring the pie filling into baked pie shells, she touched the pie crust edges and the pie filling with her gloved fingers. Cook D left kitchen with the loaded food cart for the 2 cottages, separate from the main building. When she returned to the kitchen, she donned an apron and put away clean pots/pans/utensils without washing her hands/donning gloves. When she picked up/held the items her bare fingers touched the food contact surfaces. DM got celery and onion from refrigerator. She donned gloves without washing her hands. She pulled apart the stalks and rinsed the celery. She placed a cutting board on the work surface and got a knife out of a drawer. She changed gloves without washing her hands and diced the celery then scraped the celery into a bowl. During an interview with the RD and DM on 05/18/22 at 1:00 PM they both agreed there was a definite lack of hand washing and appropriate glove use during the preparation of lunch today. They said the back kitchen door was not supposed to be left ajar as this would allow pests to enter the kitchen. They said the person who had entered with the rolling ice chest was from one of the ALF buildings. One of their ice makers was broken and the other one did not make enough ice for both houses. They said the back door had been left ajar so ALF staff could come get ice. If closed all the way the door locks automatically. They said the kitchen staff are unlikely to hear someone knocking due to the noise in the kitchen. There was a small window in the door, but the ALF staff would have to wait until someone in the kitchen noticed them through the window. The said anyone entering the kitchen is required to wear a hairnet or other appropriate hair cover/restraint. They said there should be no hand or soiled glove contact with food or food-contact surfaces. They said the cooked pie crusts should have been covered. They said anytime staff leave kitchen they must wash hands upon return. They agreed that the above failures could cause cross-contamination and place residents at risk of food-borne (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 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 676091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagecrest Alzheimers Care Center 438 Houston-Harte San Angelo, TX 76903 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 illness. Level of Harm - Minimal harm or potential for actual harm Review of Dietary/Food Service Personnel Policy and Procedures, revised 07/10/19, included the following, in part: Residents Affected - Many WORK CONDUCT: 6. Only dietary employees are allowed in the kitchen or food/supply storage areas. Residents, visitors, salesmen and other facility employees are not permitted in the department unless requested or approved by the Dietary Manager/designee. PERSONNEL APPEARANCE: 6. Employees must wash their hands whenever they may be dirty such as: a. Immediately before beginning food preparation including working with exposed food, clean equipment and utensils, and unwrapped single serve and single use items. b. After touching human body parts (including touching of hair or face) other than clean hands, and clean, exposed portion of the forearms, g. before handling food, i. whenever hands become soiled, j. after handling soiled dishes or utensils, l. when returning to kitchen after making a delivery to another area, m. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, o. before putting on gloves when starting a new task; when changing gloves; removed soiled gloves, wash hands using proper procedure then put on new gloves p. at all other times when working with or activity that could contaminate the hands. 7. ABSOLUTELY NO BARE HAND CONTACT WITH FOOD. 8. When to change gloves: as soon as they become dirty or torn, before beginning a new task, after any interruption (taking a phone call, leaving the serving area, etc.); 12. Employees will not handle food with their hands, (sic) disposable gloves or utensils will be used at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 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 676091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagecrest Alzheimers Care Center 438 Houston-Harte San Angelo, TX 76903 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 (Residents #51) reviewed for infection control. The facility failed to ensure: Residents Affected - Few Resident #51's SVN mask and oxygen nasal cannula tubing was bagged when not in use. This failure placed residents at risk for infection. Findings included: Record review of Resident #51's face sheet dated 05/21/2022 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, chronic obstructive pulmonary disease and shortness of breath. She was [AGE] years of age. Record review of Resident #51's care plan dated 05/12/2022 indicated in part: Focus: the resident needs to wear oxygen during the day, the resident likes to come out for meals and then go back to her room to rest. Goal: The resident will wear her oxygen during the day, resident will come out for meals and then rest after she eats during the day, the resident will be invited and reminded when the daily activities are going on. Interventions: Staff will remind the resident to wear her oxygen daily x 7. Record review of Resident #51's medication profile dated 05/19/2022 indicated in part: May use oxygen 1-2L via NC at bedtime related to shortness of breath. Ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization PRN Every 4 Hours related to shortness of breath. During an observation on 05/17/22 at 10:20 AM Resident #51's oxygen tube cannula was on the floor and the SVN mask was lying on the top of the bedside dresser next to some hair from an elastic hair tie and hair brush. During an interview on 05/17/22 at 10:25 AM RN A said Resident #51's oxygen tubing cannula and SVN mask were supposed to be stored in a plastic bag when not in use. The RN said it was the CNA's responsibility to place the supplies in the bag when it was removed from the resident. The RN said the resident was not able to remove the cannula herself, so it was the CNA's responsibility to store the cannula in the bag. RN A said it was the nurse's responsibility to place the SVN mask in the bag after the resident received her breathing treatment. The RN said Resident #51 was currently using the oxygen only while in bed and PRN breathing treatments. The RN said they would replace the tubing and SVN mask and place them in the bags. During an observation on 05/18/22 at 09:32 AM observed Resident #51's oxygen tubing cannula wrapped around the bedside dresser drawer. During an interview on 05/18/22 at 09:35 AM RN A said Resident #51's oxygen tubing cannula was supposed to be stored in a plastic bag when not in use. The RN said they had just placed it in a bag (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 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 676091 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/19/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sagecrest Alzheimers Care Center 438 Houston-Harte San Angelo, TX 76903 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few yesterday 05/17/22 but the staff had not stored it in the bag as they were supposed to. RN A said they would replace the tubing and get a bag to store it in again. The RN said the charge nurses would usually do rounds throughout the day and monitor to see the oxygen items were stored in the bags. RN A said the failure occurred because the staff did not store the oxygen cannula and the nurse did not store the SVN mask in the bag. The RN said if the items were not stored correctly it could lead to respiratory infections and possibility of bacteria being inhaled by the resident. During an interview on 05/18/22 at 11:04 AM CNA B said Resident #51 only used the oxygen cannula when she was in bed. The CNA said whenever they got the resident out of the bed, they stored the cannula tubing in a plastic bag. CNA B said she was not sure who got the resident out of bed that morning. During an interview on 05/19/22 at 3:20 PM the DON said the SVN masks and nasal cannulas were supposed to be cleaned and stored when not in use. The DON said the nurses would monitor that the oxygen items were stored properly. The DON viewed a photo of the SVN mask taken by the surveyor where it showed the mask lying next to the hair and hairbrush and he said that was not the ideal way to store the mask. The DON said if the oxygen cannula was left on the floor and then used again it could lead to respiratory infections. The DON said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. During an interview on 05/19/22 at 3:25 PM the Administrator said they did not have a policy for storing oxygen nasal cannulas or SVN masks. The Administrator said the expectation was for staff to store the cannulas and SVN masks in an area that was considered clean. The Administrator said it was everyone's responsibility to make sure the items were stored safely. The Administrator said the oxygen items left on the floor could lead to respiratory infections. The Administrator said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. Record review of the facility's undated policy titled Surveillance for infections indicated in part: Process surveillance reviews practices related directly to resident care, such as monitoring of compliance with transmission-based precautions, hand hygiene, use of disposable gloves, ensuring sterile procedures are appropriately followed, ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676091 If continuation sheet Page 5 of 5