Inspection·April 19, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. 3. The facility failed to store foods in accordance with professional standards. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: On 4/17/24 at 8:54AM an initial observation of the kitchen was conducted. Inspection of the freezer revealed: 1 food service bag of frozen chicken quarters with no received date, no open date and open to air, 2 food service bags of frozen chicken quarters with no received date. 1 food service bag of frozen chicken [NAME] with no received date, 7 10-lb. chubs of frozen hamburger meat with no received date, 1 zip seal bag of frozen chicken nuggets no received date, and no open date, 2 3-gal. containers of vanilla ice cream with no received date, and no open date, 1 2.6-lb. frozen apple pie with no received date, no open date and, 1 10-lb. box of frozen sliced carrots with no received date, and no open date, and open to air. Inspection of the refrigerator revealed 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: 675016 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 675016 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Great Plains Nursing and Rehabilitation 315 E 19th Dumas, TX 79029 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)