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 observation, interviews, and record review, the facility failed to store, prepare, distribute food in
accordance with professional standards for food service safety for one of one kitchen reviewed for food and
nutrition services.
The facility failed to ensure the food was properly stored in the freezer and the pantry.
This failure could place residents at risk being served food that could have been crossed-contaminated,
frost bitten, and foodborne illness.
Finding included:
Observation on 03/11/2024 between 9:30 am and 10:30 am revealed an open bag of frozen fish was
undated in the walk-in freezer. The box of fish was pulled forward to show the DM the fish was exposed,
and he stated the staff was going to cook it that day. Continued observation walking throughout the freezer
revealed there was a box of chicken nuggets open and exposed which was 2 boxes down on the same
shelf with the fish. There was a box of what appeared to be hamburger patties open and exposed.
Observation of the pantry revealed there was an open and exposed bag of crotons. The DM stated that it
was wrapped up as there was plastic wrap around the bag. However, the top of the bag was open and
exposed.
Observation on 03/13/2024 between 11:00 am and 12:00 pm revealed cake served from the previous day
was in the refrigerator exposed on a rack.
In an interview with CK 1 on 03/13/2024 at 11:45 AM, CK 1 stated once the food was opened it should be
wrapped and labeled. He stated once he opened the boxes and he does not use all the food, he wrapped
and labeled the food. CK 1 stated if the food was not closed or wrapped up, it can be freezer burnt and
rodents or anything can get into the pantry food items, then the food will have to be thrown away; which will
become costly.
In an interview with CK 2 on 03/13/2024 at 12:00 PM, CK 2 stated if the food was exposed in the freezer, it
will get frost bitten but it should not be wrapped up. CK 2 stated once a box or bag was opened, it should be
closed, wrapped, and dated. CK 2 stated if the food is exposed it can be at risk of cross contamination. CK
2 stated he did not open any food and leave it exposed. CK 2 stated he properly closed the food, labeled,
and dated it, and placed it in the designated area within the kitchen.
In an interview with DM on 03/13/2024 at 2:30 PM, DM stated his expectations of his employees
(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:
675533
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
675533
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Spicewood Summit
4401 Spicewood Springs Rd
Austin, TX 78759
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
regarding their kitchen duties was to keep everything safe and compliant, provide high quality food and
services, and to respect everyone. DM stated that food left exposed in the refrigerator could be spilled onto
other food items, cross-contaminate foods. DM stated foods left exposed in the freezer could cause
cross-contamination and freezer burn. DM stated foods left exposed in the pantry could spill onto other
items or get contaminated by pests. DM stated all of this could cause food-borne illness. DM stated staff is
trained on food preparation, handling, and pathogens. DM stated the administration is responsible for
ensuring annual training is completed. DM stated that it is his responsibility to ensure staff had updated
food handlers licenses.
In an interview with the DM on 03/13/2024 at 3:30 PM, DON stated her expectations for the kitchen staff is
to provide high quality food and service, attention to detail, and do it in a safely manner. DON stated if food
is left exposed in the refrigerator/freezer, it can be crossed contaminated with spillage from other foods, and
end in product loss. DON stated if food is left exposed in the pantry, it can possibly be contaminated by
pests and spillage from other foods, and end in product loss. DON stated the kitchen staff is trained on food
borne illness and pathogens on in the computer-based training system. DON stated it is the Administrator's
responsibility to ensure the staff completed their training. DON stated the staff has food handling license.
DON stated it is responsibility of the DM to make sure the licenses are current.
A record review of the facility's undated policy titled Storage - Refrigerator and Freezer reflected the
following: All foods used in the dietary departments are received, stored, and issued in a timely fashion to
reduce deterioration, contamination, and loss.
A record review of the facility's undated policy titled Storage - Supplies reflected the following: To provide for
safe and sanitary storage of dietary food and non-food supplies.
A record review of the facility's undated policy titled Storage - Dry Goods reflected the following: All foods
used in the dietary department are received, stored, used in a timely fashion to reduce deterioration,
contamination, and loss.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675533
If continuation sheet
Page 2 of 2
