Inspection·August 5, 2021

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure the kitchen pantry and the walk-in cooler were clean and in good repair, and failed to ensure the walk-in freezer was maintained to prevent the potential of food contamination. The facility also failed to use non-expired sanitizing strips to ensure proper concentration of the sanitizer in the manual washing sinks. Findings: 1. On 8/02/21 at 10:23 AM, the main kitchen pantry had black biofilm like substance that had leaked on the wall from the pipelines that went into the walk-in freezer. The Kitchen Manager (KM) acknowledged the black biofilm substance on the wall and said that it had been there for weeks. On 8/04/21 at 11:46 AM, the refrigeration service representative said there was air extraction and infiltration from the walk-in freezer around the fire tape seal in the pantry which allowed penetration of moisture into the pantry. On 8/02/21 at 10:23 AM, the walk-in cooler had a sour milk-like odor. On 8/03/21 at 11:08 AM, the walk-in refrigerator still had a sour odor present. The floor tiles in front of the freezer door were broken and did not allow for the floor to be thoroughly cleaned. On 8/05/21 at 10:18 AM, dietetic technician (DT) and the KM said there was a routine cleaning schedule for the walk-in refrigerator which included mopping the floors. It did not include removing and wiping the refrigerator racks or the milk storage area in the refrigerator. They said there was no specific written protocol for cleaning of the cooler, such wiping down racks to maintain cleanliness. On 8/05/21 at 3:26 PM, assistant maintenance staff said that the tiles had not been replaced in the refrigerator because it was always too moist to allow replacing the tiles. On 08/02/21 at 10:23 AM, the walk-in freezer entrance door had ice build-up on the corner of the door. The freezer door had an ice moisture streak approximately 8 inches from handle side at floor and around seal of door. Inside the freezer was ice buildup on the ceiling, the back wall and on the evaporator fan unit. Directly under the evaporator fan unit were a case of strawberries, 2 packages of English muffins, wrapped dinner rolls, and ice cream. These food items did not allow proper air circulation in the freezer. There was a potential of the ice contaminating food products stored throughout the freezer. At 10:32 AM, the KM said the ice buildup had been a problem for months; maintenance had looked at it a few times, but it was still happening. (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: 105207 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 105207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Melbourne Healthcare and Rehabilitation Center 1415 S Hickory St Melbourne, FL 32901 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)