Inspection·June 6, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 for 1 of 1 kitchen. Residents Affected - Some 1. The facility failed to ensure partial loaf with over half of loaf used was dated with the opened date. 2. The facility failed to ensure opened bagged elbow pasta was dated with the opened date. 3. The facility failed to ensure twenty-five-pound opened bag of corn meal was sealed and dated with opened date. 4. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 06/03/2024 at 11:20 a.m. during the initial tour of the kitchen the pantry revealed a partial loaf of bread with over half the loaf used. The end of the bread bag was tied off in a knot without an open date. The pantry further revealed an opened bag of elbow pasta in a large zip lock bag with a received date of 04/29/2024, but no opened date. A twenty-five-pound bag of corn meal was observed open on the bottom shelf of pantry with top of bag open to air without an opened date. During an interview on 06/03/2024 at 11:36 a.m. [NAME] A stated the bread in the pantry should have been dated when it was opened and placed back in the pantry. She further stated it was used for sandwiches that morning. [NAME] A stated she was not sure when the pasta had been opened but an opened date should have been placed on the bag with a use by date. She further stated the corn meal usually was placed in a container after it was opened and dated. [NAME] A stated the corn meal being opened and not sealed could have allowed bugs to get in it and it could have caused cross contamination. [NAME] A stated dates are necessary so they know when something was opened and how long it had before it should be used. Observation and interview on 06/04/2024 at 4:57 p.m. of the kitchen revealed [NAME] B and the DA with facial hair restraints not worn properly. [NAME] B was observed with his mustache exposed and the right side of his beard not totally restrained while he demonstrated the preparation of the pureed (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: 675373 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 675373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Whispering Springs Rehabilitation and Healthcare C 506 S 7th St Carrizo Springs, TX 78834 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)