Health inspection·January 25, 2024

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, facility failed to ensure kitchen staff were competent in job duties related to testing the sanitization solution concentration in the low temperature dishwasher. Residents Affected - Some This failure has the potential for improper cleaning and sanitization which could lead to increase in risk for food-borne illness for 57 out of 57 residents. Findings: During a concurrent observation and interview on 1/22/24 at 9:30 a.m., in the kitchen, with Certified Dietary Manager (CDM) and Dietary Aide (DA1), DA1 was observed testing the sanitizer solution concentration of the low-temperature dishwasher. DA1 was observed letting the dishwasher run for two cycles, then taking the litmus test strip and dipping the strip on the residual water left on the plate covers for 5 seconds. CDM reminded DA1 that litmus paper should be dipped in the water at the bottom of the dishwasher. DA1 then dipped the litmus paper into the rinse water reservoir. CDM stated that DA1 should not test the rinse water reservoir since it is contaminated and the litmus paper needed to be dipped into the water at the bottom of the dishwasher. During the same observation and interview, DA1 stated sanitizer concentration in the dishwasher needs to be 120 ppm (parts per million). A review of facility's Dietary Aid job description, dated 2003, indicated the Dietary Aide performs a number of kitchen duties including Perform dishwashing/cleaning procedures . A review of facility's policy and procedure, titled Sanitization, dated 2008, indicated low-temperature dishwasher b. final rinse with 50 parts per million (ppm) hypochlorite (chlorine) . 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: 056457 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 056457 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenridge Post Acute 2150 Pyramid Drive El Sobrante, CA 94803 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)