Health inspection·April 24, 2025

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 observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food was labeled properly in the refrigerator. The facility failed to ensure food was discarded per manufacture instructions. The facility failed to ensure that staff performed hand hygiene when entered the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 04/22/25 between 10:10 AM and 10:30 AM, of the kitchen, the DM entered the kitchen from the dining room and failed to perform hand hygiene when he entered the kitchen. The refrigerator contained a container of ham, out of its original container, was not labeled with an item description, open date or a use by date and an open carton of thickened milk with an open date of 04/02/25 and manufacture instructions on the container that stated, Discard if not used within 4 days of opening. During an observation on 04/22/25 at 11:20 AM, the DM entered the kitchen from the dining area and failed to perform hand hygiene. The DM retrieved a scoop from a drawer and handed it to the Cook, prior to performing hand hygiene. During an interview on 04/24/25 at 11:42 AM, the DM stated his expectation was food out of original container, in the refrigerator, should have been labeled with food description and open date. The DM stated the thickened milk should have been discarded per the manufacture recommendations. The DM stated all staff were responsible to check food for freshness, label food with open date, use by date and item description. The DM stated he was responsible to monitor and that he checks items daily. The DM stated residents could have been exposed to foodborne illness if food was not labeled correctly, or if food was not discarded per manufacture recommendations. The DMs stated what led to the failure was that staff had gotten sidetracked. He stated prior to him becoming DM, there had been staff turnover. The DM stated what led to failure of the thickened milk was that the other products had a 7-day discard and he had overlooked it. The DM stated his expectation was that hand hygiene be performed upon entrance into kitchen and when hands became soiled. The DM stated staff had been trained and were responsible to know to perform hand hygiene, and he was responsible for monitoring. The DM (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: 675038 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 675038 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clyde Nursing Center 806 Stephens St Clyde, TX 79510 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)