Inspection·August 11, 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, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Residents Affected - Some Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen. Findings included: Observation of the kitchen food prep activities on 8/10/23 from 10:45 a.m. to 11:15 p.m. revealed the following: At 10:40 a.m., [NAME] A was observed in the kitchen preparing purees for the lunch meal on 8/10/23. While preparing the pureed meals [NAME] A did not change her gloves during the activity. [NAME] A washed hands and applied gloves to her hands. [NAME] A walked to the oven, opened the oven doors, and took out a pan of beef casserole. [NAME] A closed the oven doors. [NAME] A set the pan onto the counter, removed the foil covering, picked up a scoop and scooped the required amount of casserole into a blender container. [NAME] A then placed the foil covering back over the casserole pan, opened the door to the oven and placed the casserole back in the oven. [NAME] A removed the pan of vegetables from the oven. [NAME] A closed the oven doors, removed the foil from the vegetable pan and scooped vegetables into a blender container. [NAME] A replaced the foil on the vegetables and placed the pan of vegetables back into the oven. [NAME] A closed the oven doors and took both blender containers to the blending machine across the kitchen. [NAME] A got 2 serving pans and 2 scoops from the shelf and brought them to the prep table. [NAME] A blended the meat casserole touching the lid, blender controls and the prep table while blending the puree. [NAME] A picked up the blending container from the base with her gloved hands and set the blender container on the counter. [NAME] A blended the vegetables and then picked up each blender container and poured the blended meat casserole into the serving pan and covered the pan with foil. [NAME] A then poured the vegetables into the serving pan and covered the pan with foil. [NAME] A then opened the bread wrapper and pulled a slice of bread from the wrapper and tore the bread into pieces with her gloved hands and put the bread into a 3rd blender container. [NAME] A then reached into the bread wrapper with her gloved hands and pulled 4 slices of bread from the wrapper and tore the bread with her hands and placed the torn bread into the blender. [NAME] A picked up a carton of milk opened the container with her gloved hands and poured the milk into the blender. [NAME] A picked up another container of milk and dropped it on the floor. [NAME] A walked to the cooler, removed a carton of milk, and brought the milk to the prep table, opened the (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 4 Event ID: 676461 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 676461 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country View Living 701 Butler Blvd. Dimmitt, TX 79027 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)