Health inspection·November 22, 2023

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 observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation Residents Affected - Many The facility failed to ensure food was stored properly in the walk-in freezer and walk-in refrigerator. There was food that had been expired and food that had not been labled or dated. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings include: Observations on 11/22/2023 at 9:20 am of poster titled FIRST IN FIRST OUT posted on the outside of the walk in refrigerator informing the staff to label food the day food was received and when it should be used. Store food so labels are clearly visible and use products expiring first. Check food expiration dates and throw away at or before expiration. During an observation of the walk-in freezer on 11/22/2023 at 9:23 am multiple boxes of food were observed laying on the floor including an opened box of hamburger meat, pies, French fries, muffins, and wedge cut potatoes. A bag of carrots was observed laying on the floor of the freezer in the corner. During an observation of the walk-in refrigerator on 11/22/2023 at 9:25 am a plastic wrapped pack of pastries with a use by date of 10/24/2023 was seen on a shelf. Further observation revealed what appeared to be raw hamburger meat in a zip type bag, unlabeled and undated. The meat was in a square white tub and blood juices from the meat was observed in the tub. An observation of the walk in refrigerator on 11/22/2023 at 9:26 am revealed a large bowl of salad type food covered with plastic wrap, unlabeled and undated as well as what appeared to be celery and onions in zip type bags unlabeled and undated. During an interview on 11/22/2023 at 9:23 am the DM stated they had gotten a food delivery yesterday. She stated the food was supposed to have been put away last night but I guess he didn't do it and I didn't follow up to make sure it got done. She stated it was her responsibility to make sure food was stored properly and her responsibility to follow up and make sure it got done. She stated improper food storage could lead to contaminated food and food borne illness and could make the residents very sick. She stated I'll have to do some more in-services. I did a bunch of in-services after the yearly survey , but I guess I need to do more. She stated they had received a citation for food (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 4 Event ID: 675826 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 675826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunset Home 1800 West 9th St Clifton, TX 76634 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)