Health inspection·September 9, 2022

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 food in accordance with professional standards for one of one kitchen food service safety in that: Residents Affected - Some -The facility stored unlabeled food in the refrigerator and the freezer. This failure had the potential to place residents that eat from the kitchen at risk of foodborne illness. Findings included: Observation and interview on 09/07/22 at 9:07 a.m., revealed 1 bag of unlabeled lettuce in the walk-in refrigerator;1 unlabeled bag of frozen waffles, and 1 unlabeled bag of fried chicken. The Lead Kitchen Aid Manager stated the bags should be labeled. He stated food needs to be labeled so that residents were not served food that had gone beyond the expiration date and that it was safe for the residents. In an interview with the Director of Food Services Supervisor on 09/08/2022 at 12:30 p.m., she stated that the policy for storing food is when foods are placed in the fridge they are placed in bag and labeled with the prep date and the used by date. The Director of Food Services Supervisor was asked why labeling was important and she stated labeling was important to ensure that spoiled food was not served to residents. In an interview with the DON on 09/08/2022 at 1:52 p.m., the DON stated that the facility used the Texas Food Establishment Rules or TFER as their food storage and labeling policy. Record Review of Inservice training of Labeling and Dating of Products dated 06/21/2021 reflected in part: .If you open a package, make sure it put into a sealed bag or container and a label with an opened date and use by date Record review of In-service training on Label and dating, rotating product conducted on 06/12/2021 read in part: . When you open a new box of product and you do not use it all, an OPEN DATE needs to go on the box and product is to be put back in the same place you got it from A record review of the August 2021 version of the TFER reflected the following: (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. (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: 676194 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 676194 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mason Creek Transitional Care of Katy 21727 Provincial Blvd Katy, TX 77450 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)