Health inspection·August 12, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 8/12/24 at 9:57 a.m., an observation of the three-compartment sink revealed it was set up and in use by the CDM. He stated the first sink was for washing, the second sink was for rinsing, and the third sink was for sanitizing. The CDM stated the sanitizer was checked with a test strip at the start of each shift, at each water change, and should be written on the log. An observation of the sanitizer solution log for August 2024 revealed entries were missing for multiple dates. The CDM and Sr RD stated they expected the log to be filled out. On 8/12/24 at 11:00 a.m., an observation of Staff A, [NAME] revealed she was putting prepared food on the steam table for the lunch tray line. She stated the digital thermometer she was going to use, to determine the temperature of the food, was calibrated that morning. Staff A stated she ran the thermometer under hot water until it reaches 80 degrees Fahrenheit, she removed the thermometer from the water and watched the temperature drop until it stabilizes. She stated this was how she calibrated the digital thermometer. On 8/12/24 at 11:10 a.m. to 11:44 a.m., an observation of Staff A revealed she used the same gloves throughout the following tasks: touched the pen and logbook multiple times to write down the meal temperatures, tear open and remove individual sanitizer wipes to wipe down the thermometer in between taking temperatures of the foods, and the removal of two prepared foods in their pans to two clean pots to reheat the foods on the stove. An observation at 11:21 a.m. revealed Staff A had cooked meat on her right gloved fingers while she was taking the temperature of the cooked fish. An observation at 11:28 a.m. revealed Staff A was stirring the cooked meat on the stove with a ladle then placed her gloved finger into the ladle containing the food. An observation at 11:29 a.m. of Staff A revealed she was stirring cooked noodles on the stove with a ladle then placed her gloved finger into the ladle containing the food. On 8/12/24 at 11:24 a.m., an observation of the plate warmer revealed two plates with missing pieces on the rim. On 8/12/24 at 11:42 a.m., an interview with the Sr RD revealed there were two methods used to calibrate the digital thermometers. She stated one method was an ice bath where the temperature should reach 32 degrees or the boiling water method to which the temperature should reach 200- 220 degrees. The Sr RD stated the cooks calibrated the thermometers. She stated herself and the CDM educate staff on how to calibrate the thermometers. The Sr RD stated there was an education calendar to include topics under food safety, physical safety and clinical nutrition. On 8/12/24 at 11:44 a.m., an observation of Staff A revealed the right thumb of her glove was ripped. During the time of the observation, Staff A was handling prepared food on the steam table. On 8/12/24 at 11:57 a.m., an observation of Staff B, Dietary Aide revealed he placed plastic lids onto bowls containing pineapple cake. At the time of the initial observation, he was not wearing gloves. During the observation, the Sr RD approached Staff B. Further observation revealed he stopped what he was doing, walked away from the bowls, then returned shortly after and was wearing gloves. Observations of Staff B revealed he continued the task of placing plastic lids on the bowls with the pineapple cake. On 8/12/24 at 12:03 p.m., a second observation of the plate warmer revealed two plates with missing pieces on the rim were still there. The Sr RD was present during the observation and was made aware. Further observations revealed the Sr RD removed the two plates from the warmer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 If continuation sheet Page 2 of 3 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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 On 8/12/24 at 2:49 p.m., an interview with the Sr RD revealed staff were expected to wear gloves when they touch a ready to eat food or if they have bandages on their hands. She stated she expected gloves to be changed if the gloves became soiled, if staff needed to touch clean items, gloves became ripped, if staff touched their face or clothing, or if they were changing activities. Residents Affected - Many Photographic Evidence Obtained. A review of the facility's policy and procedure titled, Storage, dated June 2024, revealed a procedure for refrigerator storage to include the following: 11. Label all prepared items with the product name, preparation date and use by date. Further review of the facility's policy and procedure for, Storage revealed the following under freezer storage: 8. Cover all prepared items with plastic wrap or foil to prevent off-flavors, drying, and/or cross-contamination. A review of the facility's policy and procedure titled, Preparation, dated January 2024, revealed a procedure for preparation to include the following: 2. Use single-use gloves while preparing and serving all ready-to-eat foods. 3. Change gloves: a. With each new task. A review of the facility's policy and procedure titled, Cooking, dated June 2024, revealed a procedure for cooking to include the following: 1. Handle food safely before and after it is cooked to prevent contamination and bacterial growth. A review of the facility's policy and procedure titled, Cleaning and Sanitizing, dated June 2024, revealed the following under the policy, The facility promotes a safe, clean, and sanitary environment for its employees, residents and visitors. The Food and Nutrition Services team maintains clean and sanitary kitchen facilities. Walls, floors, ceiling, equipment, dishware and utensils are clean and/or sanitized and in good, working order. Further review of the policy revealed procedures to include the following: 7. Food and Nutrition Services staff will follow appropriate procedures for cleaning and sanitizing kitchen equipment. 11. Three-Compartment Sink Procedure for Pots, Pans, Cooking Utensils and Equipment: ii. Record PPM [parts per million] on the Sanitizer Solution Log. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105283 If continuation sheet Page 3 of 3