Health inspection·October 5, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many be consumed after the use-by date and could make the residents sick because bacteria could be growing by then. An interview with the HC on 10/03/23 at 11:45 a.m. revealed she had been off work for a couple of days. When asked if she had been here yesterday, she stated yes and shrugged her shoulders as to why she did not dispose of the expired foods in the refrigerator. Interview with the DM on 10/03/23 at 11:47 a.m. stated the logs did not look right, and that the numbers written for the temperatures and chemicals should have some variation; they should go up or down. The DM stated the dietary aids were responsible for entering accurate numbers in the logs. The DM stated the cooks were responsible for the aids, and he was responsible for the cooks and everyone else. The DM stated he had not looked at the logs since he started here 5-6 months ago because he assumed the staff were taking care of it. The DM stated the point of having temperature and chemical logs was to make sure everything was clean, the temperature was right (to get dishes clean), and the chlorine was right to disinfect and sanitize the dishes. The DM stated he would not be having this problem (residue in the dishes) if the logs were right. The DM stated it was important to have accurate logs, so they could follow trends and take care of problems before the problem. The DM stated he should have been looking at the logs. A request for in-services and training for temperatures and chemical logging for the dishwasher were requested. A record review of the dietary staff time sheets revealed the COOK worked 09/26/23-09/29/23 and recorded the refrigerator logs but did not dispose of the expired foods in the refrigerator. The HC worked on 10/02/23 and 10/03/23 and recorded refrigerator temperatures but did not dispose of the expired foods in the refrigerator. The COOK was unavailable for interview throughout this investigation. Record review of the dishwasher temperature logs dated from December 2022 to the present day revealed the same numbers in all columns, on all days and shifts. The morning wash temperatures and the final rinse temperatures were all documented to be 120F. All sanitizer documentation was 100 ppm. The exception was June 2023, three-compartment sink, where the water temperature was consistently 200F and the sanitizer was consistently 120 ppm. The three-compartment sink was checked twice daily instead of three times daily. There was missing documentation for the three-compartment sink for June 1-4, 15-18, 23-25, and 29 for the third service. There were no other logs provided for the three-compartment sink. There were no logs at all provided for the months of January, February, March, April, May, July, and October 2023. Record review of the facility policy titled, Food Receiving and Storage rev. 01/13 documented 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Record review of the facility policy titled, Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment dated 10/01/18 documented: 7. a. The temperature of the wash water must be at least 120 degrees Fahrenheit. 7. f. A test kit or other device that accurately measures the parts per million concentrations of the solution must be available and used. A sample Dish Machine Temperature and Sanitizing Log follows this Policy. Record review of the Dish Machine Washing and Sanitizing sample documented: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 2 of 3 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 10/05/2023 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)

F 0812 *Wash-120 degrees Fahrenheit Level of Harm - Minimal harm or potential for actual harm *Final Rinse 50 ppm (parts per million) chlorine on dish surface in final rinse . Residents Affected - Many References: FDA Food Code .refrigerated, ready-to-eat, time/temperature controlled for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit for a maximum of 7 days. The day of preparation shall be counted as day 1. TAC 228.111 (p) Warewashing equipment (three-compartment-sink) determining chemical sanitizer concentration: concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Figure: 25 TAC 228.111(n)(1) Sanitizer Concentration range: 25-49 ppm, when the minimum temperature is 120 degrees Fahrenheit FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675170 If continuation sheet Page 3 of 3