Inspection·July 17, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of resident records and interviews with staff, the facility failed to conduct timely comprehensive minimum data set (MDS) assessments and transmit assessments per the required timeframes for three residents (#2, #35, #21) out of six residents reviewed for MDS, out of a total of 20 residents in the sample. Findings included:A closed record review for Resident #2 revealed she was admitted to the facility on [DATE] and discharged [DATE]. Minimum data set (MDS) assessments were completed as required on 3/28/25 and 3/31/25; however, neither assessment reflected an accepted status. Resident #35 was admitted to the facility 2/12/25 and discharged [DATE]. The discharge MDS assessment was completed on 3/31/25 but was not submitted. Resident #21 was admitted on [DATE] and discharged on 3/10/25. The last MDS assessment completed for her was 3/4/25. There was no discharge assessment completed. An interview was conducted with the MDS Coordinator on 07/17/2025 at approximately 10:00 AM. She reviewed the MDS Management Center reports and confirmed Resident #2's discharge assessment was never submitted. She explained this resident's assessment dated [DATE] was an End of Stay Part A discharge MDS. It was submitted and uploaded to the electronic record keeping platform by the former MDS Coordinator, but she must have neglected to enter the accepted date into the system. She confirmed Resident #21's discharge assessment was never completed and submitted, nor was Resident #35's. (Photographic evidence obtained) Event ID: Facility ID: 105326 If continuation sheet Page 2 of 6 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 105326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Towers Inc 3501 Bayshore Blvd Tampa, FL 33629 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 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 observations, staff interviews, and facility record review, the facility failed to 1. Ensure staff completed hand hygiene between soiled dish handling and receiving of clean dishes when operating the dish washing machine, and 2. Ensure liquids such as milk were held at a temperature of 40 degrees Fahrenheit (F) and below prior to serving to residents.Findings included: 1.On 7/14/2025 at 10:25 a.m. the kitchen was toured with Staff A, Dietary Manager. He revealed he had a full complementary staff to support the thirty-three residents who resided at the facility and that all his Dietary Staff were trained and in-serviced on subject matters to include use and sanitation of food preparation equipment, personal hygiene, food sanitation, and kitchen cleaning operations. He revealed he, along with most of his staff are Serve Safe certified, which includes the knowledge of Kitchen/Food Sanitation. Staff A, Dietary Manager revealed the kitchen operates a High Temperature dish washing machine and revealed it is maintained by an outsourced maintenance company. He confirmed there had not been any recent concerns with the machine and he receives the proper soaps/detergents and supplies to run the machine effectively. Staff A, Dietary Manager revealed the machine, as a High Temperature dish washing machine, and per the machine's specifications, it should operate with a wash temperature of over 165 degrees Fahrenheit and above, and a rinse temperature of over 190 degrees Fahrenheit and above. Observations of the machine's metal specification plate attached to the undercarriage of the machine revealed a wash temperature to reach at least 150 degrees Fahrenheit and above, and a rinse temperature to reach 180 degrees Fahrenheit and above. A wash cycle demonstration was asked to be performed by staff. Staff A, Dietary Manager, revealed Staff D, [NAME] was the operator of the machine this morning. Staff D, [NAME] was asked how he operates the machine. Prior to Staff D, [NAME] being asked about the machine, he was observed to handle many soiled trays of eating ware with his bare hands, as well as touching soiled breakfast meal tray carts with his bare hands. Staff D, [NAME] was the only staff member who was observed in the dish machine room and had been observed operating the machine while Staff A, Dietary Manager, was interviewed just five minutes before. Staff D, [NAME] revealed the facility operates a High Temperature dish washing machine and he has been adequately trained on the use of the machine. He also denied any recent concerns with the machine, and he responded that the wash temperature should reach over 150 degrees Fahrenheit, and the final wash cycle should reach at least 180 degrees Fahrenheit. Staff D, [NAME] was then asked to perform a demonstration on how to operate the dish washing machine. Staff D, [NAME] then grabbed a metal sheet tray with his unwashed bare hands, pre rinsed the tray with a water spray down, then placed the tray in the dish washing machine. He then closed the door with his bare hands and the machine operated with both wash and rinse cycle. The machine's wash and rinse cycle met the machine's wash and rinse temperature criteria and then stopped. Staff D, [NAME] then opened the door of the machine and grabbed the metal sheet tray with his bare unwashed hands and placed it in a clean dry storage area. Staff D, [NAME] was the only staff member to utilize the machine during this observed tour time and he continued to handle soiled eating ware to include plates, eating utensils, pans, cups, and bowls with his soiled hands, pre rinsed said eating ware and placed in empty crates and then pushed the crates through the soiled side of the dish washing machine. Each time the machine was completed with its wash/rinse operation, he would then open the door with his soiled bare hands and pull the crate out and handle all the cleaned eating ware/cooking ware with his unwashed bare hands. Staff D, [NAME] was observed operating the machine by himself, feeding soiled eating ware in the machine and grabbing the cleaned eating ware with his unwashed bare hands for a period of at least ten minutes. Staff A, Dietary Manager, was in the vicinity and did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105326 If continuation sheet Page 3 of 6 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 105326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Towers Inc 3501 Bayshore Blvd Tampa, FL 33629 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 Residents Affected - Some redirect or ask Staff D, Cook, to wash his hands after handing soiled eating ware and other soiled equipment, and prior to handling cleaned eating ware and other clean equipment. On 7/16/2025 at 1:55 p.m. during a second kitchen observation, Staff B, Dietary Aide was observed in the dish washing machine room and was performing dish washing tasks by himself. Staff B, Dietary Aide, was observed handling and touching soiled dishes, eating utensils, eating ware with his bare hands and scraping and rinsing those dishes and eating ware with his bare hands as well as doing a pre rinse at the sink next to the soiled side of the dish washing machine. He continued to take the pre rinsed eating dishes and eating ware with his bare hands and placed them in empty plastic crates. Staff B, Dietary Aide, was observed to push the soiled crates of eating ware, and other equipment through the soiled side of the machine and closed the machine's door. After the machine completed its wash and rinse cycle, Staff B, Dietary Aide then opened the machine's door with his unwashed bare hands and pulled the crate out and handled each individual piece and placed them in a drying or clean storage area. Staff B, Dietary Aide, was noted to do this same cycle of feeding soiled eating ware with his unwashed bare hands, placing them in the machine and grabbing all the cleaned eating ware with the same unwashed bare hands for at least five cycles or at least ten minutes. When Staff B, Dietary Aide, was asked if he knew what type of dishwashing machine he operates, he could not say whether it was a High Temperature or Low Temperature machine and, could only say the product name of the machine. On 7/17/2025 at 9:18 a.m. an interview with Staff A, Dietary Manager provided a verbal and physical demonstration of us of the dish washing machine. He revealed both Staff B, Dietary Aide and Staff D, Chef/Cook, were not in this morning and therefore those two staff members could not be interviewed related to the dish washing machine process. The Dietary Manager revealed the following process:Soiled dishes/eating utensils/eating ware are brought from the floor/unit and placed near the dish machine room. The soiled dishes are then placed on a metal trough and at a sink, where soiled dishes are scrapped and rinsed of food debris.The dishes/eating utensils/eating ware are then placed in a plastic crate rack and pushed through the dish washing machine. The door to the dish washing machine is then closed and by closing the door, the machine will start and operate both wash and rinse functions. After the machine is finished with both washing and rinsing, the machine's door is lifted up. At this time, staff operating the machine should be washing their hands prior to touching and receiving the washed items. Staff, after placing soiled rack of dishes/eating ware/eating utensils in the dish machine, should walk over to the nearest hand washing sink and wash their hands appropriately prior to touching cleaned dishes/eating ware/eating utensils. While Staff A, Dietary Manager was explaining the dish machine operations, Staff C, Dietary Aide was observed to place an empty tray rack on the floor, walked away from the dish machine room, handled other boxes and items, walked back to the dish machine room and then grabbed a crate of clean eating utensils and picked up individual forks, knives, spoons with her bare hands. She then placed them in another clean container. Staff C, Dietary Aide, left the dish machine room and pushed away soiled tray carts that were brought in from the unit/hallways. These carts had soiled trays that were brought back in from the breakfast meal service. She then walked back into the dish machine room and grabbed an already cleaned rack of dishes with her bare unwashed hands and then removed plates with her bare hands and placed them in another storage area. It was found Staff C, Dietary Aide, did not wash her hands after touching soiled eating ware and soiled equipment and before touching clean eating ware and eating equipment several times within a span of at least five minutes. Staff A, Dietary Manager, confirmed Staff C, Dietary Aide, should have washed her hands after touching the soiled eating ware/equipment and before touching newly cleaned eating ware/equipment. An interview with Staff C, Dietary Aide revealed she did not remember if she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105326 If continuation sheet Page 4 of 6 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 105326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Towers Inc 3501 Bayshore Blvd Tampa, FL 33629 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 Residents Affected - Some washed her hands before touching the washed eating ware/eating equipment. Staff C, Dietary Aide knew she should be washing her hands after handling soiled equipment or touching other things prior to receiving clean dishes from the dish washing machine. Staff A, Dietary Manager, confirmed all Dietary Staff are trained and in serviced on the proper use of the dish washing machine and also trained and in serviced on proper hand washing techniques while conducting operations in the kitchen. 2.During the first initial kitchen tour with Staff A, Dietary Manager on 7/14/2025 at 10:25 a.m. Staff A, Dietary Manager brought the state surveyor out from the main kitchen and into a food service Staging room, just outside the main kitchen space. Staff A, Dietary manager revealed this food service Staging room is used to store cooked and prepared foods from the kitchen and to plate and serve food items from the steam table. The Staging room was observed in a room between the main kitchen and the main dining room and had equipment to include 1. a handwashing sink, a counter space with cabinets and drawers, a small refrigerator with a freezer compartment, a steam table to hold food at appropriate food holding temperatures and a space to assemble trays of food. Also, the room was observed to store meal tray carts to place meal trays in. Staff A, Dietary Manger revealed they use this Staging room/space as means to serve the residents better and becomes a more homelike eating experience. Upon opening the small refrigerator, it was observed with various items to include many cartons of milk, cups of juices, plastic containers of other liquids, and other cold storage food items. Further observation revealed the refrigerator did not have a thermometer to see what the inside temperature was held at. There was a refrigerator temperature log at the door of the refrigerator, and it was documented with daily temperatures for the month of 7/2025. The temperatures were documented to include temperatures of 41 degrees Fahrenheit and below. However, there was no thermometer in the refrigerator or freezer compartment of this unit. Staff A, Dietary Manager, confirmed there was no thermometer in both compartments of the unit and did not know where they were or where they went. On 7/16/2025 at 12:27 p.m. Staff C, Dietary Aide was observed to prepare trays in the Staging room with cups, eating utensils, cartons of various milk types, cups of juices, cups of yogurt. She then placed the trays in various meal tray carts in preparation to receive plated food from the steam table area. Staff C, Dietary Aide prepared approximately fifteen to twenty of these trays with cold liquid items. They sat in the meal tray carts for at least fifteen minutes. An interview with Staff C, Dietary Aide revealed she prepares the trays with the liquids and stores the trays in the meal carts until she gets the plates of hot food items. She or other dietary staff will push the meal tray carts to various halls out in the unit. She revealed this was her normal process and she does this to save time. Staff D, [NAME] and Staff A, Dietary Manager, both confirmed Staff C, Dietary Aide's tray set up process. Staff C, Dietary Aide said she had removed the cold fluids including cartons of milk out from the main walk-in refrigerator from the kitchen about fifteen to twenty minutes prior to the observation/interview. Staff D, [NAME] was asked to pull a carton of milk at random from one of the tray carts to do a temperature demonstration. Prior to temping a random carton of milk, he and Staff A, Dietary Manager, revealed the holding temperature of cold fluids such as milk, should be at 40 degrees Fahrenheit or below. At 12:34 p.m. Staff D, [NAME] performed a random temperature demonstration with one of the random cartons of milk that were on a meal tray ready to go out to residents. He utilized his digital thermometer and revealed it was recently calibrated with a cup of ice and water. He then opened the carton of milk and positioned the stem of the thermometer in the milk. He held the thermometer in place in the milk for twenty seconds and the temperature read 63.2 degrees Fahrenheit. Staff A, Dietary Manager, Staff D, [NAME] and Staff C, Dietary Aide, confirmed the holding temperature for the milk, should have been below 40 degrees Fahrenheit or below. Staff A, Dietary Manager, said he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105326 If continuation sheet Page 5 of 6 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 105326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canterbury Towers Inc 3501 Bayshore Blvd Tampa, FL 33629 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete would need to remove all the milks stored in the tray cart and replace them. He did confirm the milks would have gone out to residents during this observation, prior to checking the temperatures. On 7/17/2025 at 8:45 a.m. Staff A, Dietary Manager and Staff D, [NAME] were asked to revisit the Staging kitchen area where the small refrigerator/freezer was positioned. It was found on 7/14/2025 the unit did not have a thermometer in either the refrigerator or freezer compartment. Upon observing the refrigerator/freezer on 7/17/2025 at 8:45 a.m., the door was opened and there was a thermometer placed on the top shelf. The thermometer read 34 degrees Fahrenheit. There were cartons of milk placed on the shelving of the unit. Staff A, Dietary Manager, was asked to remove one of the milk cartons and test the milk for temperature. He confirmed the digital thermometer he had was calibrated via cup of ice and water. Staff A, Dietary Manager, pulled out a carton of milk, opened the pour spout and placed the digital thermometer in the milk and held it for twenty seconds. The thermometer read 49.4 degrees Fahrenheit. The Dietary Manger confirmed the milk was not being held or did not hold to a temperature below 41 degrees Fahrenheit. He could not say how long the cartons of milk were stored in the refrigerator but revealed the milks would have been served to residents. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the meal service Ware Washing in Meal Service Pantries policy and procedure with a revised date of 5/2023. The policy revealed; The community will follow established methods for the safe and effective use of dishwashers in the meal service pantries. The procedure revealed; #4 - Staff will use proper hand washing techniques prior to unloading and storing clean dishes. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the meal service Taste and Temperature Control policy and procedure with a last revised date of 5/2023 for review. The policy revealed; Food is maintained at palatable temperatures during service to meet resident expectations. The procedure revealed; #3 - Temperatures of hot and cold food will be taken again if food is delivered in bulk to service pantries to ensure temperature maintenance. #6 - Cold foods, such as milk, butter, ice cream, and juices should be refrigerated during service or held on ice or insulated bins to maintain proper temperature 40 degrees Fahrenheit or lower. On 7/17/2025 at 1:00 p.m. Staff A, Dietary Manager provided the Food Safety Management System policy and procedure with last revision date 5/31/2025, for review. The policy revealed; Hands must be washed frequently and correctly, including at the following times; After handling soiled equipment or utensils. The policy further revealed; Employees must clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using liquid soap in a dedicated handwashing sink:- Rinse under clean, running warm water;- Apply soap;- Rub together vigorously for at least 10-15 seconds while paying attention to removing soil from underneath the fingernails during the cleaning procedure and creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms; fingertips, and areas in between the fingers;- Thoroughly rinse under clean, running warm water;Immediately follow the cleaning procedure with thorough drying using disposable towel or hand dryer;- To avoid re-contaminating their hands or surrogate prosthetic devices, employees may use a disposable paper towel or similar clean barriers when touching surfaces such as manually operated faucet handles on a handwashing sink or the handle of a restroom door. Event ID: Facility ID: 105326 If continuation sheet Page 6 of 6