Inspection·October 4, 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 observation interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Residents Affected - Some The facility failed to ensure: The food items in the walk-in refrigerator in the kitchen were labeled and dated. The food items in the freezer were not stored on the floor. These failures could place residents at risk for food-borne illness, and food contamination. Findings included: Interview and observation of the walk-in refrigerator in the kitchen on 10/04/23 beginning at 10:30AM revealed the following items had no name and/or prepared and 'use by' dates on them: 1. One plastic bag which contained slices of cheese. 2. One plastic bag which contained shredded cheese 3. One tray with two packets of yellow pasty substance. The packet was immersed in a pool of yellow liquid. The DM identified it as whipped raw egg removed from the freezer for thawing. 4. One large box of bacon. 5. One container of dark brown substance. The DM identified it as jelly. Observation of the walk-in freezer in the kitchen on 10/04/23 beginning at 10:30AM revealed a box of food items stored on the floor. During an interview on 10/04/23 at 11:15 AM, the DM stated all the food items stored in the refrigerator should have been labeled and dated appropriately. Every item needed to have the name of the food, the date they removed from the freezer for thawing or date of preparation and 'use by date' on the packet/container. He stated the staff working in the kitchen were instructed to follow the facility policy for food storage and preparation, however someone did not do the job correctly. He stated he did random inspection in the kitchen storage for compliance as he was responsible for ensuring (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 3 Event ID: 675956 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 675956 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of Duval 5301 W Duval Rd Austin, TX 78727 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)