Health inspection·September 15, 2022

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, the facility failed to ensure the food and nutrition services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to facility policies and standard of practice when: 1. The Dietary Aide (DA) could not correctly demonstrate how to test the dishwashing machine for sanitation. 2. No temperature log for the dishwashing machine These failures had the potential to result in contamination of food leading to widespread food borne illness for 16 residents who consume food from the kitchen. Findings: 1. On 9/14/22 at 10:00 A.M., an interview with DA 1 was conducted. DA 1 stated, she was the assigned dishwasher for the shift. DA 1 stated, she would check the temperature of the dishwasher machine before starting the wash. DA 1 further stated, she would test the machine water by using a test strip; if the color of the test strip was dark the machine was good if not dark, add solution and run the machine again. DA 1 stated I do not record the temperature or the test strip, no one told me that it needed to be recorded. On 9/15/22 at 9:00 A.M., an observation and interview with DA 2 was conducted. DA 2 demonstrated how he tested the sanitizer strength in the dishwasher machine. DA 2 took a test strip from a test strip container, he placed the strip in the machine water, waited for 15-30 seconds and removed the test strip from the water. DA 2 compared the test strip color against the sanitizer color indicator. DA 2 stated, the deep green color test strip indicated 300-400 parts per million (ppm) and that was the proper sanitizing level. DA 2 checked the temperature gauges on the dishwashing machine. The temperature reading was 150 degrees. DA 2 stated, I think the machine temperature is ok, I do not know what the temperature is supposed to be, so I do not know if it is not ok. 2. On 9/15/22 at 9:10 A.M., an interview with DA 2 was conducted. DA 2 stated, he did know that he had to record the dishwasher machine temperature. There was no record of temperatures logged. On 9/15/22 at 9:15 A.M., an observation and interview with DA 1 was conducted. DA 1 started to use the dishwasher. The first run was a rack of serving trays. DA 1 did not checked the temperature gauges before, during or after the wash. DA 1 then placed a rack of glassware and did not checked 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: 555906 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 555906 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Village Christian Retirement Community 100 Holland Glen Escondido, CA 92026 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)