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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, 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 unit refrigerators.
1.
The facility failed to ensure foods were labeled in order to identify the contents and dated when opened.
2.
The facility failed to ensure food was properly stored in designated areas at all times.
These failures could place residents who ate food from the unit refrigerator at risk of food borne illness and
disease.
Findings Included:
Observation of the unit refrigerator located in the medication room [ROOM NUMBER]/25/24 at 8:50 AM
revealed the following:
1.
A clear plastic container with a green top which contained a yellow substance that appeared to be pudding
had no label and was did not have the date it was prepared.
2.
A plastic bag of chips and dips had no label to identify the contents and did not have the date they were
prepared.
3.
A Whataburger cup with dark liquid that was stuck to bottom of refrigerator door and had no label to identify
the contents and did not have the date it was placed in the refrigerator.
4.
(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:
675274
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
675274
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willis Nursing and Rehabilitation LP
3000 N Danville St
Willis, TX 77378
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
A plastic container with a frosted chocolate cupcake had that did not have the date it was stored.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 06/25/24 at 08:59 AM, LVN 1 said the substance in the clear plastic container was
pudding that the medication aide uses to give Resident's medications. LVN1 said he was embarrassed
because the refrigerator should not look like this, and he did not know who was responsible for cleaning it.
When asked why refrigerated foods should be labeled with dates and names, LVN 1 replied that was to
prevent cross-contamination or spoilage, and someone could get sick if they eat it.
Residents Affected - Some
During an interview on 6/26/24 at 1:20pm the ADON stated the charge nurses are responsible for checking
the unit refrigerator for labels and dates on the resident's food. The ADON further stated staff was not
supposed to put personal items in that refrigerator and the staff had a refrigerator in the break room for
their personal use. The ADON stated after the food was discovered without labels and dates, an in-service
was done with the staff.
During an interview on 6/27/24 at 1:25pm the Administrator stated whoever takes the food from the
Resident was responsible for placing the name of resident and the date on the item. It was a shared
responsibility between medication aides and nurses. They are the only ones with access to the room. They
are also responsible for discarding out of date items.
Record review of the facility's policy titled Resident Personal Food Policy dated 9/11/23 Procedure Section
C (d) indicated that Foods requiring refrigeration will be received by the facility designee (activity
department, food and nutrition department, charge nurse, etc.) to ensure proper and immediate storage
including labeling and dating.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675274
If continuation sheet
Page 2 of 2
