Inspection·July 27, 2023

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of nursing progress notes revealed that on 1/20/2023, Resident #3 was noted with tongue swelling after eating a peanut butter and jelly sandwich. On 1/23/2023, a nursing note documented Resident #3 returned from the hospital with an allergy to peanut butter added to her chart, and dietary having been made aware. Another observation on 7/24/2023 at 1:19 PM, was made of Resident #3 where she was noted to be in her room, in a seated, upright position in bed eating lunch. She reported that again, they had served her the wrong meal. No food allergies were documented on her food tray slip alerting staff to her peanut butter, jelly, and seafood allergies. (Photographic evidence obtained) An interview was conducted with the Certified Dietary Manager (CDM) on 7/27/2023 at 9:51 AM, who reported that the Registered Dietician (RD) was responsible for gathering the food preferences, but she, the CDM, collected them if needed. The CDM confirmed that if there were updates or changes to a resident's diet, the RD made those updates to the dietary meal tray ticket through the Meal Tracker system. The CDM further stated that both food allergies and food preferences were identified on the dietary meal tray ticket printed from the Meal Tracker system and used by the dietary staff when preparing meals. On 7/27/2023 at 10:01 AM, an interview was conducted with the Registered Dietician (RD), who reported that she met with all new residents within 24-hours of admission to review preferences and complete a weight loss and malnutrition screening. New residents were given menus to fill out with preferences identified, that were collected and given to the dietary department for the day or week. She then made updates utilizing the Meal Tracking system. When asked about Resident #3, she reported that Resident # 3 was picky about her food, was on select menus where she could select her own food and preferences and wasn't nutritionally at risk. When asked how food allergies were identified, the RD stated the Meal Tracker system identified food allergies that were printed on the meal tray ticket. The RD was asked to pull up Resident #3 in the system and confirm that her food allergies were listed to print on her meal tray ticket. The RD stated she found a glitch in the system and confirmed that Resident #3's food allergies were not being pulled through the Meal Tracker system or being printed out on the meal tray ticket and stated, that's a problem. She further stated the Regional RD would be contacted for assistance and for the time being, she would be printing a list of all the residents with food allergies, placing a note about their food allergies in the Meal Tracking system so the residents' meal tray tickets would now have their food allergies printed on the ticket. A review of the facility's policy and procedure for Food Preferences (dated January 2023), revealed under procedure: Food preferences will be updated as needed on an ongoing basis and Food preferences may be kept on file or in the meal tray card system. (Photographic evidence obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 2 of 5 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to complete the temperature log for the three-compartment sink; properly clean and sanitize the kitchen ice machine, upper-level of convection oven, can opener, and oven tray lines; date mark several open packages of bread on the bread rack, and in the refrigerator. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 7/23/2023 at 11:15 a.m. During the tour, the July 2023 Sanitizer Solution Log for the three-compartment sink was incomplete; only 7/1/2023 was logged. No date markings were observed in the refrigerator on one open, wrapped bag of greens, one box of red potatoes, one box of melons, one plastic container of cottage cheese, or on one bag of onions. The bread rack next to the shelf in the dry storage room had several open bundles of bread with no date markings. The same observations of the red potatoes, melons, and bread were made again on 7/25/2023 at 1:43 p.m. One open box of strawberries was also observed on the shelf in the refrigerator. During the same time, the Certified Dietary Manager (CDM) was notified that one package of buns was taken off the shelf and discarded by this surveyor due to observation of mold on the buns. (Photographic evidence and copies obtained) A follow-up tour of the kitchen was conducted on 7/26/2023 at 11:19 a.m. The can opener pixel holder was greasy and filled with food debris. The oven tray was filled with food debris and a liquid substance, another oven tray was filled with food debris. The left side of the convection oven was filled with grease buildup. The convection oven bottom right and left door and inside floor of the oven were covered with a grime. The inside of the drink dispenser spigot was covered with grime and was observed hanging off the counter, and a black substance was observed on and around the internal shoot of the ice machine. (Photographic evidence obtained) An interview was conducted on 07/27/23 at 10:06 a.m. with Dietary Aide D. She stated temperature logs were completed daily by staff assigned to the area. Dietary Aides were responsible for the dish machine and the Cooks were responsible for the three-compartment sink. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, she stated, Opened food is labeled with the date opened and expiration date. When asked what happened when bread was opened, used, and placed back on the bread rack, she replied, Leftover bread should be discarded. The [NAME] was responsible for cleaning the oven and oven trays. Dietary Aides were responsible for cleaning the drink machine. When there was a problem with broken kitchen equipment, the manager would report items to maintenance. She was not sure how often the ice machine was cleaned. An interview was conducted on 07/27/23 at 10:24 a.m. with [NAME] E, who stated sanitation temperatures were documented by the staff assigned on the temperature log daily. The [NAME] and Dietary Aide stored food in the refrigerator and freezer. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, she stated, Open food is wrapped and labeled with the date opened and discarded in 3-7 days. Open bread was labeled with the date opened and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 3 of 5 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 - Many date to be discarded. All staff were responsible for cleaning the ice machine. The [NAME] was responsible for cleaning the kitchen ovens weekly. [NAME] E was not sure how cleaning was logged. When asked who was responsible for reporting broken equipment, she stated, All staff can complete a work order for maintenance. An interview was conducted on 07/27/23 at 10:50 a.m. with the Certified Dietary Manager (CDM), who confirmed that sanitation temperatures were documented on the temperature log daily by the staff assigned to the task. When asked to explain the facility's policy around date marking food items for the refrigerator and freezer, the CDM replied, Open food is sealed and labeled with the date opened and the date to be discarded. Open bread was labeled and dated. The [NAME] was responsible for cleaning the ovens and the Dietary Aide was responsible for cleaning the drink machine. The oven was cleaned every two weeks. The CDM reported broken kitchen equipment to maintenance. When asked how long the oven had not worked, she replied, I think forever. The CDM stated she and Cook/Assist Manager F were responsible for wiping the inside of the ice machine every two weeks. She confirmed there was no log to show evidence of the cleaning. A review of the facility's policy and procedure titled Pot and Test Strip Log, dated January 2021, revealed: Monitor the three-compartment sink wash temperature and chemical saturation (parts per million {PPM} at each pot and pan washing in order to assure proper cleaning and sanitizing of dishes. Procedure: 3. Test the third sink well for proper parts per million (PPM) per chemical directions. 4. Record chemical saturation level by indicating PPM using the appropriate litmus paper .Forms: Sanitizer Log. (Copy Obtained) A review of the facility's policy and procedure titled Sanitation, dated September 2021, revealed: The facility strives to promote good sanitation practices to protect its residents and employees from foodborne illness. The facility sanitation process will ensure a clean, safe environment for its residents and staff. Procedure: . The food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceilings and equipment and utensils are clean and/or sanitized and in good, working order. the Centers for Disease Control (CDC) Food handling guideline is used for specific hand washing procedure. 5. Ensure food and chemical containers are labeled with name and date received. 20. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instruction procedures and Nutrition Services Cleaning Schedule. (Copy Obtained) A review of the facility's policy and procedure titled Ice Machine, dated January 2021, revealed: The ice machine, scoop and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. (Copy Obtained) Reference: 2022 Food Code, United States Food and Drug Administration. Chapter 3, Page 93 and Chapter 4, Page 127, 131, and 165. https://www.fda.gov (Accessed on 07/30/2023. 3-501.17, Commercially processed food, open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, Ready -to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Equipment, Utensils, and Linens. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. 4-6 Cleaning of Equipment and Utensils, 4-601 Objective, Equipment Food-Contact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 4 of 5 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 105533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regents Park of Jacksonville 8700 A C Skinner Parkway Jacksonville, FL 32256 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 - Many Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Equipment. 4.501.11. Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. Sanitization of Equipment and Utensils. 4-701.10 Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be sanitized. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 5 of 5