Health inspection·June 16, 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 1. The facility failed to ensure that food items past their expiration date were discarded. This failure could place residents at risk for food borne illness. Findings included: 1. Observation and interview on 06/10/23 at 11:46 a.m. while conducting a tour of the facility refrigerated walk-in storage area with DM revealed that several food items that were stored in clear plastic containers were observed to be stored past their respective expiration dates: Pureed Spaghetti dated 6/4/23, Pureed Porkchops dated 6/4/23, Coleslaw dated 6/6/23, and Vanilla Pudding dated 5/3/23. The Dietary Dir. Immediately set the foods aside for immediate disposal and stated that all left over foods should only be retained for a maximum of 72 hours and that if expired foods were served to residents, it could cause the residents to become ill. In an interview with the lead [NAME] on 06/10/23 at 12:02 p.m. the lead cook stated that Food items that were past their expiration date could become contaminated and be a hazard for residents if they (expired food items) were served. In an interview with the ADM on 06/10/23 at 1:50 p.m. the ADM stated that all foods that were past their expiration dates should be thrown out to protect residents from contracting a food borne illness. In an interview with the DON on 06/10/23 at 1:53: p.m. the DON stated that foods that were past their expiration date should be discarded because those foods could expose residents to food borne illnesses and put them at risk. Review of the facility's policy Frozen and Refrigerated Foods Storage, revised March 2019, reflected, 9. Items stored in the refrigerator must be dated upon receipts, unless they contain a manufacturer use by, sell by, best by date, or a date delivered .13 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 with 2-3 days or discarded. Review of The Food and Drug Administration Food Code dated 2017 reflected, 3-305.11 Food Storage. (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: 676237 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 676237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Belmont at Twin Creeks 999 Raintree Circle Allen, TX 75013 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)