Edgewater Care Center

F-F812

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 455724 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455724 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waterside Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

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 No contaminated foods were prepared or provided to any residents. Food was discarded immediately upon

observation of incorrect temperature. Industrial refrigeration was ordered on 6/10/2024. Due to be delivered Level of Harm - Immediate 6/13/2024. A refrigeration truck was ordered and will be delivered 6/11/2024 for cold storage. Food truck jeopardy to resident health or delivered 6/11/2024. The physician was notified of the alleged deficiency on 6/11/24 at 5:35pm. There were safety no new orders obtained. [NAME] was educated and suspended pending investigation.

Residents Affected - Some Dietary Staff has been educated on food temperatures, preparation, and service for all residents. Dietary Staff will notify the Administrator immediately if an occurrence of incorrect temperatures or questions/issues regarding food service and will follow procedures. Procedures include checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service.

6/11/2024 0830am Interventions set in place to include catered food for residents for 3 meals per day. Contact and notification for recommendations from RD E

6/11/2024 605pm RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted. There was no concern identified. The interviews were completed.

6/11/2024, 5:35p Ad-Hoc QAPI meeting was held on with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and Marketing Director, LVN to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy.

On 6/11/2024 the Administrator completed 1:1 in-service with Dietary Manger on Food Preparation and Service policy. Staff educated by administrator on 6/11/2024 on Food Preparation and Service policy.

On 6/12/2024 Dietary manager in-serviced by Registered dietician [RD H]. RD also in-service dietary staff as well.

Starting on 6/11/2024, the facility leadership (Administrator, Director of Nursing, and Regional Director) will complete education with all staff on Food Preparation and Service, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences, keep residents safe. The training was initiated on 6/11/2024 and will be completed on 6/11/2024. Staff will not be allowed to work until they receive training.

The policy pertaining to Food Preparation and Services was reviewed on 6/11/2024 by the NHA (Nursing Home Administrator), Marketing Director, LVN, DON (Director of Nursing), RDO (Regional Director of Operations), and Medical Director.

Starting on 6/11/2024, IDT (Interdisciplinary team), including Administrator, DON, Activity Director, Marketing Director, HR, BOM will meet daily after rounds Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any Kitchen refrigerators or temperatures were out of appropriate range. The findings will be immediately brought to the Administrator for further action, if necessary. Grievances will be reviewed

during morning meetings with Administrator and IDT team members for any follow-up needed. All grievances will be entered into the Grievance Log by Administrator and investigation form will be filled out accordingly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 455724 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455724 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waterside Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

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 6/11/2024 Administrator will monitor kitchen daily by doing rounds during business days for any change in kitchen refrigerator temperatures she will monitor on weekend days for one month and then random audits Level of Harm - Immediate will be provided thereafter. An audit sheet of rounding will be kept in a binder specified for follow up. Admin jeopardy to resident health or or designee will conduct audits for daily rounds for one month then periodically thereafter. Administrator will safety be notified by staff of any issues noted in the dietary department.

Residents Affected - Some 6/11/2024 Administrator will monitor refrigerator temperatures daily during business days and weekend manager will monitor on weekends for appropriate functioning and temperature utilizing a thermometer placed in refrigerator.

6/11/2024 RDO will provide physical oversight at facility weekly x4 weeks and then random reviews after.

The RDO will provide oversight of the Administrator to ensure the items on the removal plan are reviewed and completed by 6/11/2024.

Verification of Plan of Removal:

Key Observations:

Observation on 6/12/24 at 8:00 AM of the facility's parking lot revealed the presence of a refrigerated truck trailer.

Observation on 6/12/24 at 1:05 PM of kitchen revealed: the non-working walk-in refrigerator was totally empty. Further observation of three freezers revealed food items and liquids, for instance milk, and eggs that could not be frozen, that came from the temporary employee room refrigerator and the food shipment on 6/9/24 were not present in latter freezers.

Observation on 6/11/24 at noon and to 6/12/24 at 6 PM all meals had been catered.

Key Interviews:

During an interview on 6/12/24 at 8:29 AM, the FSS stated [NAME] A resigned on 6/11/24. The FSS stated a refrigerated truck trailer parked in the facility's parking lot arrived on 6/12/24 at 2:00 am. The FSS stated permission had not been granted by upper management to start cooking on site; meals were catered. The FSS stated she discussed the diet needs for residents on puree and mechanical soft with the dietician.

During telephone interview on 6/12/24 at 9:00 am, Dietician D stated: she provided guidance to the facility on

the catered meals involving regular, mechanical soft, and puree during the emergency (IJ).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 455724 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455724 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waterside Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

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 During a group interview on 6/12/24 at 4:40 PM, Dietary Aide F, the FSS, Dishwasher G , and [NAME] C, stated: they received training on to notify the Administrator immediately if an occurrence of incorrect Level of Harm - Immediate temperatures or questions/issues regarding food service and will follow procedures. Procedures included jeopardy to resident health or checking refrigerator temperatures daily, following policy and procedures for Food Preparation and Service. safety Highlights of the training was that refrigerators needed to have temperature logs and any food in the food danger zone (41 degrees F and 135 degrees F) and to notify the FSS before cooking once temperatures Residents Affected - Some were taken. The FSS stated once she was notified of any danger zone issues her plan was to dispose of the food and notify the dietitian. The group stated the training was provided by Dietician H.

During an interview on 6/12/24 at 4:51 PM, Dietician H stated he trained all 8 dietary staff and the top three highlights of the training were: safe food temperatures, storage and keeping track of refrigerator temperatures especially danger zone temperatures.

In interviews on 06/12/2024 from 5:30 PM. to 6:00 PM with 4 day shift (6 AM. to 2 PM.) 2 activities, 1 HR, 1 marketing, 6 evening shift (2 PM. to 10 p.m.) nursing staff (1 LVNs, 2 CNAs) and 3 kitchen staff; and 4 night staff (10 PM to 6 AM) 1 NA, 1 LVN, 1 CNA, and 1 CMA revealed they had been in-serviced on food temperatures, danger zones temperatures, food storage, and the Food Preparation and Service policy.

During an interview on 6/12/24 at 5:50 pm, the Administrator stated that issues involving food storage, food temperatures and/or refrigerator logs would be follow-up for investigation if issues or grievances were raised.

During an interview on 6/11/24 at 6:00 pm, the RDO stated that she would provide physical oversight at the facility weekly x4 weeks and then random reviews after.

During telephone interview on 6/12/24 at 6:07 PM, the Medical Director stated she was notified of the IJ on 6/11/24 and issued no new orders.

During an interview on 6/12/24 at 7:20 PM, [NAME] C stated, the back-up plan in case the new refrigerators went out in the future was to release a refrigerated truck until the issues with the refrigerators were fixed or new refrigerators purchased.

During an interview on 6/12/24 at 7:22 PM, the FSS stated: the back-up plan in case the new refrigerators went out in the future was to release a refrigerated truck until the issues with the refrigerators were fixed or new refrigerators purchased.

During an interview on 6/12/24 at 7:25 PM, the Administrator stated the back-up plan was to re-lease a refrigerated truck until the issues with the new refrigerators were resolved.

During an interview on 6/12/24 at 7:58 PM, the DON stated: RNC assessed all residents in facility for any GI symptoms including nausea, vomiting, diarrhea. No symptoms noted and there was no concerns identified.

During a joint interview on 6/12/24 at 8:00 PM, the RRC (regional reimbursement consultant, RN) and the RNC completed 100 % assessment of residents for GI issues and no issues surfaced requiring contacting

the MD for new orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 455724 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455724 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waterside Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

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 Key Record Reviews:

Level of Harm - Immediate Record review of facility signed in sheet dated 6/12/24 revealed all dietary staff (total of 8) received training jeopardy to resident health or on food storage and temperature safety and temperature logs. safety

Record review of GI assessments dated 6/11/24 revealed 78 residents were assessed and no issues noted. Residents Affected - Some

Record review of facility's education on food service revealed the training started 6/11/24 around 10: 00 AM and completed on 6/11/24 for a total staff of 78. [facility had 3 shifts: 6 AM-2PM, 2PM-10PM, and 10PM-6 AM].

Record review of facility's purchased order dated 6/10/24 revealed anticipated date of two refrigerators was 6/13/24.

On 06/12/2024 at 8:32 PM, the Administrator was informed the POR was validated and immediacy was removed. However, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of pattern due to the facility's need to install two new refrigerators, safely store food track deliveries, implement food temperature logs on the new refrigerators, and audit and monitor food temperatures in the preparation of meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 455724 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455724 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waterside Nursing & Rehabilitation 1213 Water St Kerrville, TX 78028

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 34957 potential for actual harm Based on observation, interviews, and record review, the facility failed to dispose of garbage and refuse Residents Affected - Few properly for 3 of 3 dumpsters, in that:

The drain plug was damaged for Dumpsters #2. And there was garbage and debris in the vicinity of the 3 dumpsters.

This failure could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

The finding included:

Observation on 6/11/24 at 9:00 AM of the dumpster area revealed three covered dumpsters with the middle dumpster (#2) with a half plug allowing ants to enter the dumpster. Behind the three dumpsters were garbage, paper items, a face mask, a gasoline can, discarded water sprayer, and numerous other garbage items spread out in the vicinity of the three dumpsters.

During an interview on 6/11/24 at 12:37 PM, the Administrator stated that the plug to the second dumpster needed to be replaced and that she intended on calling the dumpster company. The Administrator stated that there was garbage behind the dumpsters and was caused by a storm the past two days. The Administrator stated that part of the garbage included a gas can without gas in it in the vicinity of the dumpsters. The Administrator stated that the dumpster site needed to be cleaned.

During an interview on 6/11/24 at 12:40 PM, the Maintenance Supervisor stated he was responsible for cleaning the dumpster area. The Maintenance Supervisor stated that there was garbage around the dumpster site, it needed cleaning, and he was responsible for the cleaning of the area. The Maintenance Supervisor stated that he checked the dumpster area daily. He had no explanation for the garbage in the vicinity of the dumpster area. The Maintenance Supervisor stated that the middle dumpster (#2) needed a working plug so as to discourage pests and rodents.

Record review of facility's Food-Related Garbage and Refuse Disposal policy dated Revised October 2017 read, .Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . Storage areas will be kept clean at all times, and shall not constitute a nuisance .Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . [the policy did not address dumpster plugs]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 455724