Health inspection·August 18, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the dishwasher and soaking the dispensers overnight in sanitizer solution. She said that cleaning is documented on checklists that dietary staff are responsible for completing daily. The DM said she did not know why it had not been cleaned the night before and that the beverage dispenser was the only source of juice and water for all resident meal trays. The DM said it was important to keep food contact surfaces clean to prevent cross contamination and all residents from getting sick. The DM said there were several new hires for dietary and planned for all the new staff to obtain their food handler certifications by Monday, 8/21/2023. The nozzle was observed to be removed from the beverage machine and cleaned and the can opener was cleaned and sanitized in the dishwasher. The DM said she would provide re-education on cleaning and storage and instruct an aide to fix the paper towel dispensers as soon as possible. The DM said she would have to look for the manufacturer's instructions for the beverage machine and did not know when it was last serviced by the owning company. During an interview on 08/17/2023 at 3:02 PM, RP A said Resident #1 complained of the water and juice tasting funny and she was concerned that the water may be contaminated and contributing to the urinary tract infections for Resident #1. RP A said a physician informed her Resident #'1's urinary tract infections could be due to contaminated water and he was concerned that there was mold in the water. During an interview on 08/18/2023 at 11:06 a.m., LVN A said she was aware Resident #1 complained about the water. She said there were no additional residents that had concerns related to the water provided at the facility and that Resident #1 would have food and drink brought in by food delivery services or family. LVN A said Resident #1 was from a different state and attributed the concern to the water being from a different source than where she was originally from and did not notify administration/ management staff or file a grievance on the concern. During an interview on 08/18/3023 at 1:52 p.m., the DM said she is ensuring the beverage handle and nozzles are being kept clean by referring to the checklist for cleaning list and that she had conducted in-service on cleaning and sanitizing. During an interview on 08/18/2023 at 3:10 p.m., Dietary Aide A said he had been employed at the facility for 2 months. Dietary Aide A said he was responsible for cleaning the beverage nozzles and other food contact surfaces and that the Dietary Manager also assisted when needed. Dietary Aide A said all staff were responsible for cleaning and sanitizing food contact surfaces on a daily basis on the evening shift and that he did not know why the nozzles had not been cleaned and sanitized. Dietary Aide A said staff complete checklists to record areas they have cleaned. He said that he had not received training or re-education on 8/17/2023 or on 08/18/2023 and that the last in-service he attended was on 08/01/2023. During an interview and record review on 08/18/2023 at 3:28 p.m., there was one dietary in-service, dated 8/1/2023, including a topic of cleaning and sanitizing. Checklists for cleaning, no date, revealed record of cleaning for a future date. The DM said the checklists provided had no date and were from the current week and 8/19/2023, Saturday, was checked as completed by mistake. The DM said she did not provide a documented in-service on 08/17/2023 and would be conducting checklist and cleaning re-education by the end of the day on 08/18/2023. Review of In-service, dated 8/1/2023, revealed training was provided on cleaning the ice machine, tea container, and coffee machine. Review of cleaning checklists on Friday, 08/18/2023, titled Aides, Cooks, and Dishwasher (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 2 of 4 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 Daily/Weekly Duties revealed a future date of Saturday was completed on the cleaning list and that staff were to initial and date - failure to do so will result in disciplinary actions. No initials or dates were recorded on cleaning duties completed and were recorded with a check mark. Review of Policy, titled Employee Infection Control, revised May 28, 2020, revealed the following: Residents Affected - Many Policy All local, state, and federal standards and regulations are followed to ensure a safe and sanitary Nutrition Services Department. Review of the FDA Food Code 2017, Chapter 4-602.11 Equipment Food-Contact Surfaces and Utensils, revealed how utensils shall be cleaned and sanitized: (E) Except when dry cleaning methods are used as specified under [section] 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and CONSUMER self-service UTENSILS such as tongs, scoops, or ladles; . (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Review of the FDA Food Code 2017, Chapter 6-403.11 Designated Areas, revealed how personal drinks and items shall be stored: (A) Areas designated for EMPLOYEES to eat, drink, and use tobacco shall be located so that FOOD, EQUIPMENT, LINENS, and SINGLE SERVICE and SINGLE-USE ARTICLES are protected from contamination. (B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES can not occur. 6-403.11 Designated Areas. Because employees could introduce pathogens to food by hand-to-mouth-to-food contact and because street clothing and personal belongings carry contaminants, areas designated to accommodate employees' personal needs must be carefully located. Food, food equipment and utensils, clean linens, and single-service and single-use articles must not be in jeopardy of contamination from these areas. Review of the FDA Food Code 2017, Preface 1. FOODBRONE ILLNESS ESTIMATES, RISK FCTORS, AND (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 3 of 4 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 676184 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Providence Park Rehabilitation and Skilled Nursing 5505 New Copeland Rd Tyler, TX 75703 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 INTERVENTIONS, revealed foodborne illness potential risk factors: Level of Harm - Minimal harm or potential for actual harm Preface 1. Residents Affected - Many FOODBORNE ILLNESS ESTIMATES, RISK FACTORS, AND INTERVENTIONS Foodborne illness in the United States is a major cause of personal distress, preventable illness and death, and avoidable economic burden. .especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676184 If continuation sheet Page 4 of 4