Inspection·January 30, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations and staff interviews, the facility failed to follow proper sanitation and food handling practices to prevent foodborne illness by failing to ensure: (1) Opened refrigerated foods were labeled and dated; (2) Canned goods received from the vendor and intended for resident consumption were within the manufacturer's expiration date; and (3) Food was prepared and served from a clean, sanitary kitchen. Unsafe food handling and sanitation practices present a potential source of pathogen exposure which could result in foodborne illness. This had the potential to affect all residents who consumed foods from the facility's kitchen. The findings include: During an initial kitchen tour with the Certified Dietary Manager (CDM) on 1/27/25 at 10:28 AM, the walk-in refrigerator was observed with a large, clear plastic bin containing shredded iceberg lettuce. There was no label or date on the bin. A small cellophane-covered bowl held one half of a cut onion, and a Ziploc baggie contained fresh herbs; however, neither item was labeled or dated. The bread rack in the dry storage room held several loaves of bread that had a manufacturer's date stamp of 10/20/24. The hot dog buns manufacturer's date stamp was 12/26/24. There was no label to reflect when the baked goods were received by the facility. Inspection of the canned good rack revealed six cans of pineapple tidbits with handwritten dates on each can of 1/7/25; however, the manufacturer's expiration date on the cans was 4/23/24. (Photographic evidence obtained) The horizontal surface of the table under the food steamer was soiled with debris resembling flour and food crumbs, and the legs of the steamer had build-up resembling lime/scale or rust. Some of the buildup had come off and pooled around the base of the legs. The inside of the drain underneath was coated with wet, black mildew-like matter. The floor tiles in the corner of the kitchen near the walk-in refrigerator were coated with a buildup of a black grimy substance. The drain under the pipes in the corner was surrounded by a wet, black substance that was also built up in large patches on the surface of the drain cover. Similar buildup was seen in the drain under the two-compartment sink. Splatters of dried food and hard water marks were seen on the vertical surfaces of the serving side of the tray-line steam table. The metal cart that housed the juice machine was rusted and soiled. The CDM acknowledged the unlabeled lettuce, onion and herbs in the refrigerator, confirming that each should be dated. She explained that the baked goods were all delivered frozen. She thawed them upon receipt and placed them on the racks for use. She acknowledged that there was no date on the bread or the rack reflecting when the items were received and thawed. The CDM produced an invoice for the last bread delivery, which revealed a delivery date of 12/27/24, one month ago. The CDM could not locate a delivery slip for the hot dog buns and confirmed that the handwritten date on the pineapple chunks reflected the date they were received and stocked. The CDM also confirmed the manufacturer's (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: 105447 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 105447 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Volusia Healthcare and Rehabilitation Center 1851 Elkcam Blvd Deltona, FL 32725 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)