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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to store, prepare, distribute, and serve food
under sanitary conditions in the facility's only kitchen.
The dietary staff did not accurately test the dish machine for chlorine sanitizing with the correct test strips
from 02/27/24 until 03/11/24.
This failure could place residents who ate food from the kitchen at risk of foodborne illness.
Findings included:
During an observation and interview in the kitchen on 03/11/2024 at 09:45 AM, DA A was going to
demonstrate checking the sanitizing on the dish machine and she had a container of testing strips on top of
the machine. She said she had not tested the machine yet this morning. She was finished with washing the
breakfast dishes. She ran the machine and took a test strip from the container and tested the water
containing the sanitizer. The test strip was a yellow color and had no reaction. Observation of the label on
the container of strips indicated the strips were for use on QAC (quaternary ammonium compounds)
sanitizer and not chlorine sanitizer. DA A said she had been using those strips to test the dish washing
machine since the RD told them they could use the QAC strips. She said those were the only test strips she
had to use and not the purple ones.
A review of a Facility Dish Machine Temperature and Sanitizing Log dated March 2024 and posted on the
wall by the dish machine indicated the sanitizer had been tested every day from 03/01/24 to 03/11/24 three
times a day and test results for sanitizing were noted at 50 ppm when using strips that were unable to test
for the presence of chlorine.
During an observation and interview on 03/11/24 at 11:25 AM DA A said she found some chlorine test
strips on a shelf in the kitchen. She demonstrated checking the sanitizer in the dish machine and it was
sanitizing at 100 ppm.
During an interview on 03/12/24 at11:15 AM, DM said her RD told her she could use the quaternary test
strips used at the 3 compartment sink on her chlorine sanitizing dish machine because her chlorine strips
were out of date.
During an interview on 03/12/24 at 03:30 PM the DM said the RD came in on 02/27/24 and did a kitchen
sanitation quality review and dining observations. She said she had been using the quaternary strips on the
machine since that date. She said the machine should be tested 3 times a day, once for
(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:
675011
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
675011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Jacksonville
305 Bonita St
Jacksonville, TX 75766
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
each meal where dishes would be washed. She said she had no written policy regarding when to test the
machine other than the log sheet. She said the service vendor came to the facility on [DATE] and did a
routine maintenance check and the machine was sanitizing properly on that day. She said the service
vendor came on 03/11/24 at 3:45 PM to bring chlorine testing strips and did a full maintenance check at
that time and the machine was sanitizing.
Residents Affected - Many
A review of information posted on Texas Health and Human Services website, viewed 03/14/24, indicated
quaternary solution was used primarily for three compartment sinks and test strips for quaternary
compounds indicated sanitizing was occurring when the solution was testing at 200-400 ppm.
FDA Food Code, dated 2013, viewed at FDA.gov indicated Low temperature machines using chlorine as a
chemical sanitizer should have a concentration between 50 ppm and 100 ppm and be measured using the
appropriate chemical test kits. The effectiveness of chemical sanitizers is determined primarily by the
concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the
concentration of the chemical sanitizer solution.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675011
If continuation sheet
Page 2 of 2
