Inspection·May 12, 2023

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, 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 kitchen reviewed for food procurement in that: -Food items were found in the kitchen with expired and beyond the use by date. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease. Findings include: Observation of the facility's kitchen and interview on 05/09/23 between 8:30 am and 8:45 am with the Dietary [NAME] A revealed the following: -A plastic container of Pimiento Cheese with a used by date 04/27/23 in the walk-in refrigerator. -A plastic container of sliced deli ham with a used by date 05/06/23 in the walk-in refrigerator. -A plastic container of American Sliced Cheese with a used by date 04/10/23 in the walk-in refrigerator. Interview with the Dietary [NAME] A on 05/09/23 at 8:35 AM, she said that the container of food items with expired used by date should have been used or discarded prior to the used by date. Interview with the Dietary Food Service Manager on 05/10/23 at 9:00 AM she said that the dietary staff Should have used or discarded the food prior to the used by date. Record review of facility's Policy on Food Storage dated 06/17/2021 Read in part . Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded . . 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: 675999 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 675999 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St James House of Baytown 5800 W Baker Rd Baytown, TX 77520 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)