Health inspection·August 18, 2022

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, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchens and 1 of 1 nutrition room. Residents Affected - Some There were personal food items in the kitchen refrigerator and dry storage areas, contaminated and/or broken equipment, the dishwasher temperature was below requirements, the kitchen handwashing sink temperature was above requirements, and there was expired and unlabeled food in the nutrition room. These failures could place residents at serious risk for complications from food contamination. Findings were: During the initial tour on 8/16/22 beginning at 10:25 a.m., observation of the kitchen and an interview with DS revealed a personal container of a white liquid substance labeled with the initials of the DC. There was a large drinking vessel with a name on it in indelible marker, on a high shelf, in the very back of the dry food storage area. The DS said the container in the refrigerator was not supposed to be there, nor was the container in the dry storage area. She said personal items could be stored in her office or elsewhere, but not in the food storage or food prep areas because of infection control issues that could arise with outside food and/or drink. There was a heavily dented colander hanging in the prep area that the DS wasn't sure if it was being used but could not explain why else it would be there. Three spatulas had severely melted plastic handles, creating deep crevasses and very sharp edges; one of the spatulas had a severely bent and crevassed tip. There was a 10-inch chef knife with chunks missing from the blade and about an inch missing from the tip; it was broken off. The DS removed them from the drawer the utensils were in, in the prep area and said, These should not even be here. She said the utensils were not safe to handle and that they could harbor bacteria. The low-temperature dishwasher water temperature reflected 100 degrees F when observed on 8/16/22 at 10:25 a.m. and 10:55 a.m. Low temperature dishwashers have a minimum water temperature of 120 degrees F for chemical sanitation, per manufacturer's instructions. The DM said it would get to temperature. After 4 attempts and fifteen minutes, the washer remained at 100 degrees F. The DS said she did not know how long the washer was like that and said they were supposed to be getting a new one but did not know when. The DM confirmed the DS's statement. The DA said the correct running temperature of the dishwasher was supposed to be 120 degrees F. Shesaid she did not know what she was supposed to do if it was not running at temperature. She could not say why the water temperature was important for sanitizing dishes. The DS told her she should tell someone. (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 6 Event ID: 675170 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 675170 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Nursing and Rehabilitation Center of San D 138 S Fm 1329 San Diego, TX 78384 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)