Inspection·May 5, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record review, the facility failed to ensure food was served in accordance with professional standards for food service safety, by failing to maintain appropriate dishwasher temperatures and proper sanitization of dishware. This impacted all residents who were served food prepared in the facility's kitchen. The findings include: On 5/4/23 at 10:50 AM, a kitchen observation was conducted with the Assistant Food Service Supervisor (AFSS). Dietary staff were washing trays and dishes from breakfast. Two loads were run though the low temperature dishwasher, but the analog temperature gauge did not move at any time during the wash or rinse cycles; it remained fixed at 100 degrees Fahrenheit (f). The AFSS confirmed the needle on the gauge was not moving, and that the water did not reach 120 degrees f, as required. After the second cycle, the AFSS tested the sanitizer concentration by dipping a litmus test strip into the pooled water on the just-washed trays. She reported the sanitizer should be 50 parts per million (ppm). The test strip, however, barely changed color. The AFSS held the strip to the color guide on the bottle, which included 4 different shades of purple (light to dark) and corresponded to concentration levels. The strip indicated the solution concentration was at 10 ppm. The AFSS confirmed the sanitizer concentration was too low to effectively disinfect the dishware. When asked for the dishwasher temperature and sanitizer logs, she pointed to a clipboard hanging on the wall. The clipboard contained information for the 3-compartment sink, but not the commercial dishwasher. After searching her office unsuccessfully, she asked the Food Service Director (FSD) where the logs were. He too referenced the clipboard and could not find dishwasher test logs. On 5/4/23 at 11:00 AM, The FSD reported that the vendor who services the machine had been called. He was reminded that until the machine was repaired there was a risk of foodborne illness or cross-contamination if the unsanitized dishware was used. The FSD was advised to use disposable plates and utensils until repairs were completed. On 5/4/23 at 11:05 AM, the Administrator was notified of the finding and asked to have his Maintenance Director bring the most recent dishwasher inspection and maintenance invoices. On 5/4/23 at 1:35 PM, the AFSS came to the conference room to report that the problem was fixed. She requested this writer go watch another cycle. A full cycle was run through the dishwasher, but the temperature gauge only reached 110 degrees f. She again confirmed the proper temperature was supposed to be 120 degrees f. The FSD, who was present, explained the water temperature to the machine had just been adjusted and felt the water would raise to proper temperatures after a few more cycles. The AFSS tested the sanitizer solution, which now registered somewhere between high 100s and 200 ppm. (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: 105287 Printed: 05/28/2026 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 105287 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westside Oaks Rehabilitation & Nursing Center 2061 Hyde Park Rd Jacksonville, FL 32210 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)