Inspection·June 23, 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 - Many The facility failed to ensure food items in the refrigerator were not expired. The facility failed to ensure food item in the dry storage area that required refrigeration was refrigerated. These failures could place residents at risk for food-borne illness, and food contamination. Findings included: Observations of the refrigerator in the kitchen on 06/23/2023 beginning at 12:00 PM revealed that the following items were expired: 1.One plastic bag labelled turkey had sliced meat in it. The packed date written on it was 06/06/23 and 'use by date' was 06/13/23. DM stated it was Turkey Ham 2.One plastic bag contains four sandwiches with prepared date 06/16/23 and 'use by date' 06/21/23 written on it. 3.One plastic bag containings 11 small containers with yellow creamy substance in it. Mayo, 6/1/23 was written on the bag. DM stated it was mayonnaise repacked from a large container, for day-to-day use. DM said they were supposed to be used within 7 days from the date of packing. 4.Observations of the storage area in the kitchen on 06/23/2023 beginning at 12:00 PM revealed a jar of strawberry jam that was in use, stored in the dry storage area. On the label it was written Refrigerate after opening During an interview on 06/23/23 at 12:30 PM the DM stated the expired food items should not have been in the refrigerator. DM said the food item that required refrigeration after opening should be stored in the refrigerator. When the investigator asked about the consequences of these deficiencies, DM stated inappropriate storage of food items might promote the growth of microorganisms. He added, this created opportunity for cross contamination of fresh food items in the refrigerator. DM stated the facility follows Texas Food Establishment Rules (TFER) for storing, preparing, distributing, and serving food. He said the expectation was, prepared and repacked items were disposed within 7 days (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: 676123 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 676123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairfield Nursing & Rehabilitation Center 420 Moody St Fairfield, TX 75840 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)