Inspection·November 7, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm and Employee G inserted the hose into the new bucket and showed Employee H how to do it. She placed the new bucket of chlorine bleach under the machine and went back to her task. Employee H continued to run the machine. At 11:22 am, she was asked to test the machine again. She tested it using a test strip and the test strip remained white. When asked what she was trained to do, she stated she was going to inform the CDM and left the dish room. Residents Affected - Many At 11:25 am, the DM entered the dish room and tested the water with a test strip. The test strip remained white. (Photographic evidence obtained) He then primed the machine at the top of the machine where the hose from the bucket of chlorine bleach enters the machine and ran a load of dishes. He tested the water and the test strip indicated 200+ ppm. The DM stated that the test strip was very dark and there was a lot of bleach in the water now. It was probably due to having just primed it. He confirmed that 200+ ppm was a toxic level of bleach, and he would keep an eye on it. At 11:40 am, black biological growth was observed on the interior surfaces of the ice machine. Black biological growth and dust debris was observed on the air vents over the food preparation table and the smoke alarm in the center of the ceiling in the kitchen. Black biological growth was observed on the gaskets and interior of the milk cooler. Food debris was observed on the inside of the cooler and the bottom of the milk cooler was wet with slimy black liquid with a spoon lying in it. (Photographic evidence obtained) Three large cardboard boxes containing Styrofoam cups and hinged containers with lids were observed sitting directly on the floor of the kitchen. The staff later used the products to serve the lunch meal service to the residents. (Photographic evidence obtained) The drawers of the service tables were observed to have food debris in the bottoms. Utensils in the drawers were not clean and had food debris stuck on them. Missing and broken floor tiles were in front of the prep sink, at the entry way of the kitchen, and throughout the kitchen. The tray carts were dirty clean with food debris stuck on them. The floors under the equipment and in the corners of the kitchen were not clean with a buildup of food and grease debris. The sides and back of the steam table had dried up food debris and liquid that had run down the side. The storage and food preparation table had food debris on the them. Plates stacked in the plate warmer had food debris stuck to them. Large stainless steel baking pans were observed to be wet and stacked in such a way that did not allow for air drying. The tile wall of the kitchen near the steam table and entrance had brown food and dust debris stuck-on it. (Photographic evidence obtained) A ceiling tile was hanging down above the walk-in cooler. Two large chopping knives and a long-serrated knife were observed lying on the window sill at the back of the kitchen. The chopping knives were lying on top of cooking gloves and the serrated knife was lying on the sill itself. At 11:50 am, the DM went to the sill and took serrated knife down. He took it to the prep table and proceeded to use it. He did not clean it prior to use. (Photographic evidence obtained) At 11:52 am, when asked why the knives were stored in such a manner, the DM shrugged his shoulders, shook his head and stated, I don't know. The Assistant Dietary Manager (ADM), Employee F, was observed opening a cardboard container of mashed potato flakes with her bare hands. She then pour the food into a pot of water on the stove. The ADM closed the container and put it away for future use, she did not mark a date on the box. At 11:55 am, broken floor tiles were observed in the walk-in freezer. The shelves and the floor of the freezer were not clean and had discarded food containers under the shelves. (Photographic (continued on next page) 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 11/07/2023 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 evidence obtained) Level of Harm - Minimal harm or potential for actual harm The shelves in the walk-in cooler had a buildup of food debris and the cooler walls had black biological growth on them. Under the shelves there were discarded cardboard food wrappers and food debris. A large sleeve of sliced cheese was uncovered, open to the air with no date mark on it. (Photographic evidence obtained) Residents Affected - Many At 12:00 pm, the ADM was observed to don a pair of disposable gloves without washing her hands and started to plate the food for the lunch. Shortly thereafter, she left the steam table and walked 20 feet over to the oven, opened the door, and with hot pads took a pan out of the oven. The ADM took the pan to the steam table and put it in. She did not change the contaminated gloves or wash her hands and don new gloves. At 12:40 pm, the DM stated he did not have enough staff to do the deep cleaning that needed to be done in the kitchen. He confirmed that the ADM should doff disposable gloves after contaminating them and then wash her hands with soap and water prior to donning a pair of new gloves. The DM stated he would provide an in-service for the staff who operate the dish machine to make sure they are monitoring the level of sanitizer and that the machine is functioning properly. During an interview with the Administrator on 11/07/2023 at 2:00 pm, she produced the Quality Assurance Committee Performance Improvement Plan (PIP) from the prior recertification survey when the facility had been cited for deficiencies in the kitchen. The Administrator stated that the PIP was still ongoing even though the plan was only for the three months after the survey to ensure the deficiencies were corrected. She acknowledged that the ice machine was not clean, and the plan had not been followed. She explained that the facility contracts for maintenance of the ice machine and the vendor last cleaned the machine on 09/14/2023. The Administrator stated the dietary staff clean the machine once a month, but she was unable to produce a log showing the cleaning had been done. None of the other findings during this survey were identified during the recertification survey. A review of the invoice from the vendor providing maintenance and cleaning services of the ice machine dated 09/21/2023 revealed it read: Cleaned ice machine in the kitchen. Chemically cleaned the evap and all the tube. Scrubbed the inside of the bin and reservoir. Replace water filter. Technician recommended a new machine multiple times to the client due to how old it is. Checked operation (Copy obtained) Review of the Quality Assurance Committee PIP developed after the last recertification survey conducted on 07/27/2023, revealed the facility implemented monitoring of the cleanliness of the kitchen by developing a Food and Physical Safety Auditing tool that included cleaning schedules weekly for equipment and areas of the kitchen. Floors, walls, doors, baseboards cleaned. All dishes allowed to air dry (not stacked wet), pots, pans, dishware, utensils store to prevent contamination. All cooling units clean and in good condition. All food stored properly, and date marked. All equipment clean and in good working order. The tools had been marked off as being complete as of 10/26/2023. (Copies obtained) An infection control audit tool had been developed dated 10/12/2023 that read: 4. Staff washes hands when changing tasks, including before placing gloves on hands. 7. Proper dish washing procedures are followed. Sanitizer solutions at proper PPM and temperatures within desired range and recorded. Staff can verbalize how to check PPM's and appropriate dish machine temperature. Review of the facility policy and procedure entitled Ice Machine, effective 01/2021 revealed it read: The ice machine, scoop and storage container will be maintained in a clean and sanitary (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 11/07/2023 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 condition. The ice machine will be cleaned once per month or more often as needed. (Copy obtained) Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure entitled Personal Hygiene, effective 09/2020 read: To ensure proper personal hygiene practices to prevent contamination of food. Procedure: 2. Wash hands after the following activities, including, but not limited to: After touching anything that may contaminate hands, such as dirty dishes, un-sanitized equipment, work surfaces or wash cloths. Residents Affected - Many Review of the facility policy and procedure entitled Hand Washing and Glove Use, effective 9/2020 read: hand washing is a vital role in infection control reducing the surface microorganisms on our hands. Gloves are used to provide a barrier between potential microorganisms and ready - to- eat food items being prepared and/or portioned by staff. Procedure: 1. Hands must be washed after contact with unsanitary surfaces and before wearing gloves. 5. Gloves should be changed frequently, single use task. Review of the facility policy and procedure entitled Cleaning Schedules, effective 01/2021 read: Food and Nutrition Service Staff shall maintain the sanitation of the Department through compliance with written, comprehensive cleaning schedules developed for the facility by the Food Service Manager. 5. The Food Service Manager will complete random audits to ensure personnel are compliant with cleaning and sanitizing of equipment and completion of the cleaning log. Review of the Daily/Weekly Kitchen Sanitation Checklist revised 11/04/2020 revealed it read: Main Kitchen: All reach-in and walk-in cooler clean all items covered, labeled and dated. Freezer - nothing on the floor, floor clean. Walk-ins- nothing on floor, floor clean, all food labeled and dated. Ice machine clean regular as scheduled. All food delivery carts clean in and out including wheels. Cooking area- make sure all equipment is clean and in good working order. Tray-line wiped down and sanitized under shelving clean. Kitchen floors cleaned including behind and under all equipment. Dish Room: Dish machine clean and in good working order. All utensils, pots and pans clean and stacked on rack properly to prevent wet nesting. Review of the facility policy and procedure entitled Sanitation, effective 09/2021 read: 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 it residents and staff. The Food and Nutrition Services staff identifies the potentially hazardous foods, which bacteria can grow most easily. The 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. Maintain clean and sanitary kitchen facilities and equipment by following cleaning instruction procedures and Nutrition Services Cleaning Schedule. References: Ice machines/ice bins/dispensing nozzles and lines/cooking oil storage/water vending: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned:(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee (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 11/07/2023 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 bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. https://www.fda.gov/food/fda-food-code/food-code-2022 Reference: United States Food and Drug Administration Food Code 2017. 3. PUBLIC HEALTH AND CONSUMER EXPECTATIONS. Clean environment. Page 10. https://www.fda.gov Reference: United States Food and Drug Administration Food Code 2017. Sections. 2-301.13 Special Handwash Procedures. 2-301.14 When to Wash. (A-I). Page 79. https://www.fda.gov . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105533 If continuation sheet Page 5 of 5