Inspection·April 30, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to maintain a sanitized work area. She stated she likes to clean as she goes. [NAME] C stated the red sanitizer buckets with cleaning towels are replaced with clean water and sanitizer during each shift. She stated each kitchen staff is assigned a workstation for the day and they are responsible for keeping it cleaned. Observation on 4/29/2025 at 9:35 AM revealed DD B lifting the commercial ice machine lid and searching for a leak reported to him. DD B stated to DD A he would determine where the water leak was coming from , but he would return later to complete the task. Observation on 4/29/2025 at 9:58 AM revealed a red sanitation bucket with used cleaning towels and water with sanitation chemicals sitting on top of the prepping counter within proximity of food preparation counters and within proximity of stacked clean dishes and insulated plate covers used for resident meals. The commercial ice machine's interior lid and interior frame securing lid was dirty and had brown dirt and brown slime buildup. The exterior of the commercial ice machine had a white buildup around the lower part of the machine. The commercial countertop water and ice dispenser machine in the dining room was dirty and had brown dirt and white buildup with small white particles in the drainage area. Observation on 4/30/2025 at 11:57 AM revealed the commercial ice machine's interior lid and interior frame was dirty and had buildup of brown dirt, brown slime, brown sludge with slimy texture and discoloration The exterior of the commercial ice machine had a white buildup around the lower part of the machine. The commercial countertop water and ice dispenser machine in the dining room was dirty and had brown and white buildup with small white particles in the drainage area. In an interview on 4/30/2025 at 11:49 AM DD A stated she is responsible for the day-to-day operations of the facilities' kitchen. She stated all the counters, food prep machines, dishes, refrigerators, floors the commercial ice machine, and commercial countertop water and ice dispenser machine are tasks assigned daily to staff for cleaning. She stated dietary staff are responsible for keeping their work areas clean by using the cleaning towels from the red sanitizer buckets and wiping down and washing all equipment used to prepare food. She stated that all equipment and surfaces are cleaned daily, and a cleaning log of each area cleaned is logged after completion. She stated she deep cleans the commercial ice machine monthly, but she does not keep a log of this specific task. DD A stated the commercial ice machine filters are replaced by maintenance quarterly. She stated any large repairs required in the kitchen are repaired by DD B. DD A stated she does her best to clean the ice machines daily to keep from developing mildew and growing slime. She does believe the brown dirt and buildup surrounding the lid of the machine is an issue and if it leaked into the ice the residents can become sick. DD A stated she notified DD B that the company who services the ice machine would need to provide a deep cleaning. She stated she has mentioned it in the morning meetings for the last six months and she was not sure if it was on the schedule. She stated the ice machine is working fine, but it is old, it has a leak DD B was looking at yesterday. She stated the company could replace the ice machine all together as it is extremely old, but not sure why it has not been replaced. DD A stated the ADM is aware of the ice machine as she at times will help serve ice with beverages and will scoop out ice from the machine. She has also been present in the morning meetings when she has addressed the concern. DD A stated the process to place a work order for repairs is to verbally address in morning meetings with administration staff and to verbally notify the maintenance staff who in turns will add to his workload. DD A stated the red sanitizer bucket on top of the preparation area near the stove and oven is always kept in this location of the kitchen as it is constantly used and there is no other place or room to move it to. She stated all other red sanitizer buckets are located underneath the counter spaces throughout the kitchen. DD A stated she did not see the sanitizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 - Some bucket in the prep area as a concern. She stated that the cleaning water is changed during each shift. DD A stated if the cleaning water from the sanitizer bucket were to spill or splash onto food that residents consume can be harmful to their health, but stated she and the other cooks will be cautious to avoid this from happening. In an interview on 4/30/2025 at 12:07 PM DD B stated he is responsible for making all minor repairs in the facility. He stated for more challenging repairs or outside of his skill set he will contact an outside contractor. He stated the only issues with the commercial ice machine in the kitchen is that it only makes 20 lbs. of ice, a small leak was recently identified, and he does notice light mildew, grime, and rust . He stated the grime and mildew can be removed with cleaning. This also includes the commercial countertop water and ice dispenser machine in the dining room. He stated if he were to observe large amounts of mildew, grime, and rust in either ice machine he would contract for a deep cleaning. He stated work is performed every six months. DD B stated he noticed a concern with the ice machine door/lid sticking and not opening easily. He stated he has not looked over thoroughly and has not repaired recently. He stated a leak near the ice machine was conveyed to him. He stated he recently was notified in about the ice machine lid sticking during the morning meeting but does not recall if the brown grime and brown dust layered on the interior of the machine has been mentioned. DD B stated if the ice machine is not repaired and cleaned properly it could make the residents sick. He stated he may have overlooked the ice machine as he has a heavy workload, and work orders have doubled up on him, and he has been late to morning meetings and may have not received this information verbally. He stated verbal workorders received from dietary staff are entered into the facility maintenance software, so he is aware of his workload. Surveyor requested workorders and invoices for last two commercial ice machine service requests. DD B stated he does not receive the invoices for this work and the business office may have. Surveyor requested that he reach out and request invoices through his business office. Surveyor did not receive invoices from facility. In an interview on 4/30/2025 at 12:15 PM KA D stated the dietary staff are tasked daily with wiping down kitchen equipment, washing dishes, and cleaning all kitchen surfaces before the next shift. She stated a daily log of cleaning is completed by DD A when the task has been completed. Tasks are assigned differently each day. She stated all red cleaning sanitizer buckets are changed out during each shift and are kept in low areas away from clean dishes and food consumed by residents. She stated she is not sure why there is one red sanitizer bucket left on top of the cooking prep surfaces near the stove and warming tables. She stated she is not a cook, and she does not enter the area near the stove. She stated all other buckets are located underneath the counters in a safe area away from clean dishes and food. She stated if chemicals from spillage or splashes of the red sanitizer buckets were to fall onto clean dishes or food it can be harmful to residents and their health and cause a serious illness. In an interview on 4/30/2025 at 12:26 PM ADM stated kitchen operations are managed by the DD A. She stated the dietary staff are responsible for cleaning all kitchen equipment and machines daily. She stated the DD A is responsible for notifying management staff or DD B of any kitchen equipment not functioning properly. She stated the DD B is responsible for maintaining all kitchen equipment including the commercial ice machine and commercial countertop water and ice dispenser machine. The ADM stated if the DD B is unable to repair a facility machine, he then takes the necessary steps to secure an outside contractor specializing in the repair needed. The ADM stated the process for requesting kitchen equipment and other facility repairs is to notify DD B verbally. She stated this is usually done in morning meetings with directors of each department. She stated if she received a verbal repair request during the morning meeting, she would enter a workorder in the facility's maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 - Some software and DD B will use this as a guide to work on open facility repair concerns. This maintenance system allows DD B to check off repairs he has completed and provide notification tor management that a repair is in pending status and reason, or order is requiring approval for further work. The ADM stated she is unsure why the sanitizer buckets with cleaning towels would be sitting on top of prepping tables near clean dishes and food being prepared for resident consumption. When shown pictures of the dirty ice machines and sanitizer buckets near cooked food ADM stated it was a concern and not following facility policies. The ADM stated this practice can affect the residents in a negative way and cause illness. Record Review of Policy and Procedure: Kitchen and Equipment Cleaning and Sanitation Policy, dated 12.2020 reflected: The kitchen and dining service equipment and food contact surfaces shall be maintained in a clean and sanitized condition. Dining Services staff shall be trained on cleaning and sanitizing processes. The Dietary Manager shall provide cleaning assignments to indicate the time and task to be completed by dining services staff. The Dietary Manager is responsible to ensure that cleaning assignments have been timely completed. Adequate equipment and supplies will be available for proper cleaning and/or sanitizing of dishes, equipment, work surfaces, and floors. Equipment food contact surfaces and utensils shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Record Review of Frequency of Cleaning: Kitchen and Equipment Cleaning and Sanitation Policy, dated 12.2020 reflected: Equipment food contact surfaces and utensils shall be cleaned: Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to prevent accumulation of soil residues. Clean equipment, utensils and single-service and single use articles shall be stored: Where they are not exposed to splash, dust, or contamination. Record Review of 3-304.14 Wiping Clothes, Use Limitation: FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: Soiled wiping cloths, especially when moist, can become breeding grounds for pathogens that could be transferred to food. Any wiping cloths that are not dry (except those used once and then laundered) must be stored in a sanitizer solution of adequate concentration between uses. Record Review of 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane Navasota, TX 77868 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 FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: Level of Harm - Minimal harm or potential for actual harm The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. Residents Affected - Some Record Review of 4-602.11 Equipment Food-Contact Surfaces and Utensils: FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022 reflected: Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 5 of 5