Inspection·July 19, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food sanitation and storage, in that: 1. The facility failed to ensure that foods in the dry goods storage are dated and labeled properly. 2. The facility failed to ensure items in the freezer were sealed properly. 3. The facility failed to maintain cleanliness to the dry good storage room floor. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 07/17/2023 at 3:40 p.m., with the Dietary Manager (DM) revealed the in the dry storage area there was an unlabeled, undated loosely sealed bag of bread out of the original package sitting on a dry good shelf. The DM picked up the bag and said the bread should not have been left there because it was not properly sealed and dated. Observation of dry storage area revealed two dead roaches under the food shelf racks. The freezer revealed a large metal tray container with exposed mixed veggies that was not fully covered with aluminum foil; and a bag of fried okra dated 7/7/23 was not properly sealed in a quart size Ziplock bag. The DM said t all food items should have been properly sealed in the freezer to prevent freezer burn. Observation on 07/19/2023 at 10:35 a.m., revealed a dead roach under the dry storage shelf and a dead cricket. During an interview on 07/19/2023 at 11:40 a.m., the Administrator said she expected facility food services to follow policy when it comes to ensuring food items are labeled and stored to prevent any foodborne illness. The Administrator stated the building was older and there was a problem with pest when she took over on 4/1/2023. The Administrator said pest control was coming weekly at first and now are visiting bi-weekly or anytime an issue arises. The Administrator said kitchen staff are responsible for ensuring the kitchen and storage areas of the kitchen are clean including the floors. Review of facility policy Food Receiving and Storage dated October 2022, reads in part foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Non-refrigerated (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 2 Event ID: 675017 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 675017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Country Healthcare Center 1514 Indian Creek Rd Brownwood, TX 76801 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)