Health inspection·January 8, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure care plan interventions for contracture management and hand splinting/orthotics use were developed in a timely manner for one (#96) of forty sampled residents. Findings included: On 1/5/2025 at 10:30 a.m. Resident #96 was observed in bed with his hands out from the sheets and positioned on his upper chest. Both the Left and Right hand appeared severely contracted and without any splints or orthotics on. In an immediate interview, Staff M, Certified Nursing Assistant (CNA) revealed she did not have Resident #96 on her assignment for today but has had him on her assignment many times before. Staff M stated Resident #96 received total assistance and was dependent on staff with all his Activities of Daily Living (ADLs). She could not identify if Resident #96 had any actual contractures and did not know if he utilized or wore splints or orthotics on either of his hands. She revealed she had not seen him with splints or orthotics on his hands. Staff M confirmed Resident #96 did not have any splints or orthotics on either of his hands at the time of the observation. During additional tours on 1/6/2025 at 7:44 a.m., 9:10 a.m., 2:30 p.m.; on 1/7/2025 at 7:20 a.m., 10:30 a.m., 1:45 p.m.; and on 1/8/2025 at 7:20 a.m., and 9:47 a.m., Resident #96 was observed in the same position as before. His hands were observed contracted and without any splints or orthotics on. Further observations in the room revealed no obvious signs of placed splints/orthotics. On 1/8/2025 at 10:40 a.m. an interview was conducted with Staff B, CNA and Staff C, CNA. Both Staff B and C confirmed Resident #96 required full staff assistance and was dependent on staff for all his ADLs. Staff B and C confirmed Resident #96 had limited Range of Motion in his upper Left elbow extremity. They stated therapy department staff put on an elbow brace on him but not direct care staff. Staff B and C confirmed the resident did appear to have contractures in both hands. They could not say if Resident #96 had any hand splints or orthotics available. They stated they had not seen him wearing them and wondered if that was therapy department's responsibility. Review of Resident #96's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the current Diagnosis sheet revealed diagnoses to include but not limited to: Adult Failure to Thrive, Contracture Left Elbow, Lack of Coordination, Cognitive Communication deficit, Tracheostomy, and Major Depression. Review of the most current comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed under cognition a Brief Interview Mental Status (BIMS) score of 5 of 15, which indicated the Page 1 of 21 105553 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was cognitively impaired and not able to speak related to his medical care and services. under mood and behavior, none documented as exhibited during this timeframe. For ADL - Function in Range of Motion, the resident had impairment on both sides of his lower and upper extremities. The resident was dependent on staff for personal hygiene, toileting, bathing and transfers. Review of January 2025 Medication Administration Record (MAR) for Resident #96 revealed; Resident to wear Right and Left-hand orthotics daily for up to 7 hours or as tolerated per resident preference every day shift for contracture management. Monitor skin before and after, order date 12/13/2024. This order was documented as completed and signed off each day from 1/1/2025 to1/7/2025. Observations during the dates of 1/5/2025 - 1/8/2025 revealed Resident #96 was not wearing nor offered splints/orthotics on either the Left or Right hand. Review of a document titled, Occupational Therapy Recertification and updated Plan of Treatment, period 12/29/2024 - 1/27/2025 revealed Resident #96 had a diagnosis of muscle wasting and atrophy at multiple sites. The goals for Occupational Therapy (OT) were to have the patient safely wear a resting hand splint on the Right hand for up to 8 hours with minimal signs and symptoms of redness, swelling, discomfort or pain. The assessment summary revealed interventions to include PROM (Passive Range of Motion) orthotic management and that nursing be trained on orthotic application/wearing schedule/FMP (Functional Motion Prevention) for post discharge value from OT to long term care. Review of the current Care Plans with a next review date 1/17/2025 revealed a focus on Range in Motion Resident has a risk or actual limitations in Range of Motion as evidenced by: Impairment on both sides. Interventions included to observe skin pre/post splint application and report changes. This review showed there were no care planning problem areas that identified the need for use of splints/orthotics, contracture management, or who was responsible for the placement and maintenance of splints/orthotics. On 1/8/2025 at 10:55 a.m. an interview was conducted with Staff D, Care Plan Coordinator. She revealed she was knowledgeable of Resident #96 and confirmed he did have contractures in various areas on his upper extremities. She confirmed there was care planning problem areas to include limitation of Range of Motion and with interventions and to include observing skin pre/post splint application and report changes. Staff D confirmed this problem area did not have any interventions related to the actual use of splints. She further confirmed the care plans did not have any problem areas to indicate contractures and contracture management, and to include use of hand splints/orthotics. On 1/8/2025 at 12:30 p.m. an interview was conducted with Staff E, Rehabilitation Therapy Department Director who revealed they were currently working with Resident #96 with regards to contracture management . Staff E stated the resident had returned from the hospital on [DATE] with an order dated 12/13/2024 for use of a Left hand and Right-hand splint/orthotic. Staff E revealed they had picked him up for both Physical Therapy (PT) and OT and were evaluating him with use of both splints/orthotics. She stated she was not sure why nursing had not developed a care plan to reflect the use of the hand splints/orthotics. Staff E revealed OT staff were responsible for the application of the Left- and Right-hand splint on a daily basis. Staff E was unaware Resident #96 was not offered and assisted with placement of splints/orthotics on each hand during dates 1/5/2025 - 1/8/2025 and could not speak of nursing staff documentation. On 1/8/2025 at 1:00 p.m. an interview and policy review was conducted with the Nursing Home Administrator (NHA) who provided the Restorative Nursing Program policy and procedure with a revision date 105553 Page 2 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0656 Level of Harm - Minimal harm or potential for actual harm of 10/2017. The policy revealed; The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The IDT (Interdisciplinary Team), resident and, or family identify the needs of the resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: Residents Affected - Few a.) Contracture Management and Prevention - This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. Under Topic: Restorative Nursing Programs and Guidelines. - Passive Range of Motion (PROM) + Splint/Brace Assist; PROM/AROM (Active Range of Motion) + Splint/Brace Assist. The facility did not have a specific Policy and Procedure related to the development and implementation of Care Planning problem areas. 105553 Page 3 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility did not ensure timely ophthalmology referral/consult was provided for one resident (#89) out of two residents reviewed. Residents Affected - Few Findings included: On 01/05/2025 at 10:50 a.m. an observation and interview were conducted with Resident #89 in his room. Resident #89 requested surveyor to come closer because his vision was not the best. The resident stated he had seen the eye doctor at least twice but could not recall the dates. He sated he was told he needed glasses. Resident #89 stated he had bad cataracts. On 01/06/2025 at 12:29 p.m. an interview was conducted with the Optometrist who was conducting her monthly rounds. The Optometrist agreed Resident #89 had severe cataracts affecting his vision. She stated the process was to initially reach out to social services to inform her of who she is visiting as well as social service would provide a list of residents with request for Optometry. The Optometrist stated in the next 3 to 4 days, she will send the facility a list of the residents she had visited and their assessments/referrals. The Optometrist did not know why Resident #89's referral had not been implemented. Review of Resident #89's admission record showed an original admission date of 10/23/2023 and a readmission date of 6/12/2024. Diagnoses for Resident #89 included but were not limited to: end stage renal disease, Type 2 diabetes mellitus with diabetic neuropathy unspecified, essential hypertension and cerebral infarction unspecified. Review of the most recent Minimal Data Set (MDS) for Resident #89 dated 10/29/2024 showed in Section C - Cognitive Patterns, Section C0500 a Brief Interview for Mental Status (BIMS) of 13 which indicated Resident #89 was cognitively intact. Review of Resident #89's care plan showed a vision focus area initiated on 11/02/23 - the resident has impaired visual function related to Cataracts. Interventions included: - Ophthalmology consults as ordered; date initiated 03/15/2024 - Vision consults as needed they initiated 11/02/2023 On 01/07/2025 at 10:58 a.m. an interview was conducted with Staff R, Registered Nurse/Unit Manager (RN/UM). Staff R stated she was in the process of trying to refer Resident #89 to an ophthalmologist but was not having success due to his insurance. Staff R stated, The Regional Nurse consultant is trying to help me find an ophthalmologist. Staff R reviewed the current care plan of Resident #89 and stated she could not explain why the resident was care planned for ophthalmology referral in March 2024 and care planned as a focus area for cataracts in November 2023 and they had not been done yet. On 01/07/2025 at 3:52 p.m. an interview was conducted with the Social Services Director (SSD). The SSD confirmed a list is provided to her from the Optometrist on whom she was visiting for the month. The SSD stated she will receive an email from the Optometrist a few days after her visit, but she would forward the information to the nursing staff. 105553 Page 4 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the optometrist evaluations and referrals for Resident #89 dated 7/07/2023 to current showed on 7/07/2023, 8/14/2023, 3/13/2024, 6/10/2024, 9/11/2024, and 1/06/2025 the resident was seen. Review of section titled, Treatment cataract showed referrals/consults to ophthalmologist were requested each time. On 01/07/2025 at 5:13 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA reviewed the Optometrist's referral in March of 2024 but could not state why the referral was not completed other than he may have been hospitalized . On 01/08/2025 at 12:42 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated Resident #89 may have had referrals but stated he had been a very sick man and could not leave the facility for appointments. The DON added the resident had severe kidney failure issues and may not be a good candidate for cataract surgery. Review of the facility policy and procedures titled, Referral - Vision and Hearing Services, effective November 2024 showed the following policy statement: The facility will assist residents in obtaining routine and prompt vision, hearing, care. The social services department will work to assist in or coordinate services, such as, but not limited to, the following: 1. Routine services 2. Appointments 3. Transportation to and from the office 4. Prompt referrals (i.e., broken hearing aids, glasses, etc.) 5. Family /legal representative notifications. A review of the procedure for this policy included: 1. Determine /schedule the dates for the contracted services, if applicable, to be available at the center (if possible). 2. Identify those residents who need services, including, but not limited to: a. Eye exam b. Glaucoma exam 3. Identify those residents who require a prompt referral 4. Schedule an appointment and arrange transportation as needed. 5. Document all interventions in the resident medical record. 105553 Page 5 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure care and services were provided, resulting in an actual or potential decline in a pressure ulcer for two residents (#89 and #111) of seven residents sampled. Residents Affected - Few Findings included: On 01/05/2025 at 10:51 a.m., an initial observation and interview were conducted with Resident #89 in his room. During the interview, Resident #89 stated he currently had a sore to my bottom and stated the wound had not been changed since Friday by Staff S, Registered Nurse (RN). Resident #89 stated he was told by someone the wound was getting worse but could not recall who told him this information. Resident #89 also stated the wound must be getting worse because the pain to his bottom is getting worse. On 01/05/2025 at 11:01 a.m., an observation and interview were conducted with Staff R, Registered Nurse/Unit Manager (RN/UM). With the consent of Resident #89, an observation was made with Staff R, RN/UM of Resident #89's wound. Staff R, RN/UM assisted the resident to his left side and removed the resident's brief. An observation was made with Staff R, RN/UM of no dressing present to Resident #89's wound. Resident #89 had a brief on with clean sheets and an incontinence pad underneath the resident. Resident #89 repeated the same conversation with Staff R, RN/UM in regard to his dressing not being changed for the past two days and stated the last dressing change was the previous Friday with Staff S, RN. Staff R, RN/UM stated Resident #89 must have recently had a bowel movement this morning and the Certified Nursing Assistant (CNA) removed the wound dressing and did not inform his assigned nurse. Staff R, RN/UM stated she would immediately dress Resident #89's wound after collecting the proper equipment from the wound cart. On 01/05/2025 at 11:12 a.m., an interview was conducted with Staff M, CNA, with Staff L, CNA acting as an interpreter. Staff M, CNA, who was assigned to Resident #89, stated the resident had not had a bowel movement under her care from the time she started her morning shift until the time of the interview. Staff M, CNA also stated she cleaned the resident, but only provided catheter care and did not remove the wound dressing. Review of a Resident #89's Medication Administration Audit report for 01/05/2025 showed an order for: Cleanse left gluteal with wound cleanser, apply collagen particles and Calcium alginate rope, cover with composite dressing daily and prn (as needed), completed by Staff Q, Licensed Practical Nurse (LPN) at 07:35 a.m. A record review of Resident #89's admission Record showed an original admit date of 10/23/2023 and a readmission date of 6/12/2024. Diagnoses for Resident #89 include but are not limited to: end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy unspecified, essential hypertension, cerebral infarction unspecified, obstructive and reflux uropathy unspecified, unspecified dementia unspecified severity without behavioral, psychotic mood or anxiety disorders, and respiratory syncytial virus newly added on 4/19/2024. A review of Resident #89's physician orders showed the following orders: - Cleanse left gluteal with wound cleanser, apply collagen particles and calcium alginate rope, 105553 Page 6 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 cover with composite 3 x 3 dressing daily and as needed for dislodgement, order date 11/12/2024. Level of Harm - Minimal harm or potential for actual harm - Juven one time a day for nutritional supplementation: administer one packet mixed with 240 milliliters (ml) of fluid one time a day, record the % consumed, ordered 01/07/2025. Residents Affected - Few - Acetaminophen tablet 325 milligrams (mg) give two tablets by mouth every six hours as needed for mild pain do not exceed three grams per 24 hours, over the counter medications provided by facility, ordered 8/19/2024. A review of Resident #89's most recent Minimal Data Set (MDS) assessment dated [DATE] showed in Section C - Cognitive Patterns, Section C0500, a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #89 was cognitively intact. The Assessment also showed in Section GG Functional Abilities, Section GG 0170, Resident #89 was dependent for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to chair transfer, and tub/shower transfer. Section GG 0130 showed Resident #89 was dependent for toileting hygiene, shower/bathe self and lower body dressing. Section M - Skin Conditions showed, Section M0210, Resident #89 had one current or unhealed pressure ulcer/injuries at each stage. Review of Resident #89's Skin and Wound Evaluation V7.0 weekly wound team's assessment showed the following: - On 12/03/2024 Resident #89's left gluteus wound measured 3.2 centimeters (cm) in length, 1.8 cm in width and not applicable to depth for a total surface area of 4.6 cm2 (squared). - On 12/10/2024 Resident #89's left gluteus wound measured 2.2 cm in length, 1.1 cm in width, 0.2 cm in depth and a total surface are of 1.8 cm2. - On 12/17/2024 Resident #89's left gluteus wound measured 3.0 cm in length, 1.3 cm in width, 1.2 cm in depth and a total surface area of 3.0 cm2. - On 12/31/2024 Resident #89's left gluteus wound measured 2.5 cm in length, 1.5 cm in width, and not applicable to depth for a total surface area of 2.9 cm2. - On 01/07/2025 Resident #89's left gluteus wound measured 2.5 cm in length, 1.6 cm in width, 0.5 cm in depth and a total surface area of 3.3 cm2. On 01/06/2025 at 4:15 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility has their own wound therapy team who makes their official wounds weekly, every Tuesday morning. Their wound team consists of the DON, ADON (Assistant Director of Nursing), and both Unit Managers. The DON stated the facility also uses a consultant wound company for monthly rounds, but their representative is available for consultation anytime. The DON stated the wound care orders will be implemented daily by the nurse assigned to the resident. The wound treatment times are scattered over the various shifts so as to not put too much wound responsibility on one nurse. The DON stated Resident #89 arrived at their facility with many open areas of skin and has greatly improved over the course of time. The DON could not state why the dressing was off and stated, [Staff Q, LPN] is very conscientious about her care to her residents. On 1/07/2025 at 11:25 a.m., an interview was conducted with Staff A, LPN/UM related to wound care. Staff A, LPN/UM confirmed wound rounds are done every Tuesday with the DON, ADON, and herself along 105553 Page 7 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the other unit manager. Staff A, LPN/UM stated rounds will start as early as 6:30 a.m., but she will arrive by 5:00 a.m. to ensure supplies are readily available for wound care. Staff A, LPN/UM stated if the DON or ADON are not available, then often the wound rounds will be re-scheduled for the next day but confirmed no later. Staff A, LPN/UM also stated the nursing staff is responsible for daily wound dressing changes and skin assessments and if a CNA or nurse notice a skin concern for a resident, it will be brought to her attention, and she will evaluate the area of concern immediately. Staff A, LPN/UM stated if further assessment is needed, she will notify the DON, ADON, or the other UM to perform an assessment. On 1/07/2025 at 2:33 p.m., an observation was conducted with the facility's wound team consisting of the DON, ADON, and both UMs. The wound team started their rounds with Resident #111. Resident #111 denied the need for pain medication prior to wound/dressing care. Staff R, RN/UM oversaw removing the old wound dressing and cleaning the wound, Staff A, LPN/UM measured the wound for length and width via a software system device, the ADON measured the depth of the wound and apply the new dressing as per physician order, and the DON assisted in turning the resident. When Staff R, RN/UM was asked how the wound looked, she stated it had been a while since she had seen it. An observation was made of Resident #111's back with two open areas on his buttocks and coccyx area. A strong, foul smell was noted on the removed dressing with a moderate to large amount of yellow-red drainage. Resident #111 had an open area on his right heel and was treated with betadine and the wound was left open to air. Resident #111 was observed with extremely dry skin and a large callous-like area on his left heel. Review of Resident 111's admission Record showed an original admit date of 10/08/2024 and a readmission date of 11/27/2024. Diagnoses for Resident #111 include but are not limited to: displaced spiral fracture of shaft of left fibula subsequent encounter for closed fracture with routine healing, essential hypertension, major depressive disorder recurrent, type two diabetes mellitus without complications, muscle wasting and atrophy not elsewhere classified multiple sites, benign prostate hyperplasia without lower urinary tract symptoms, obstructive and reflux uropathy unspecified, unspecified dementia moderate without behavioral, psychotic, mood, and anxiety disturbance, and acute pyelonephritis. Review of Resident #111's physician orders showed orders as follows: - Treatment as follows apply betadine to right heel every shift for blister, ordered 11/27/2024. - Oxycodone HCL 5 mg give one capsule by mouth every six hours as needed for pain, order date 11/27/2024. - Treatment as follows: Coccyx with Dakins, pat dry and apply medi honey and calcium alginate cover, with 4 x 4 every day shift for wound, ordered 12/17/2024. - Treatment as follows: Cleanse right glute with Dakins, pat dry and apply medi honey and calcium alginate, cover with 4 x 4 every day shift for wound, ordered 12/17/2024. - WBAT (Weight Bearing As Tolerated) with no restrictions, ordered 12/20/2024. A review of Resident #111's Skin and Wound Evaluation V7.0 weekly wound team's assessment showed the following: 105553 Page 8 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 Level of Harm - Minimal harm or potential for actual harm - On 12/03/2024 Resident #111's right heel wound measured 0.5 cm in length, 0.4 cm in width, and not applicable to depth with a total surface area of 0.2 cm2. - On 12/10/2024 Resident #111's right heel wound measured 0.0 cm in length, 0.0 cm in width and not applicable to depth with a total surface area of 0.0 cm2. Residents Affected - Few - On 12/31/2024 Resident #111's right heel wound measured 2.3 cm in length, 1.8 cm in width and not applicable to depth with a total surface area of 3.1 cm2. - On 01/07/2025 Resident #111's right heel wound measured 2.8 cm in length, 1.4 cm in width and not applicable to depth with a total surface area of 2.9 cm2. The wound was noted as dry flaky and scab. - On 12/17/2024 Resident # 111's right gluteus wound measured 6.5 cm in length, 3.0 cm in width and not applicable for depth with a total surface area of 15.2 cm2. - On 12/31/2024 Resident #111's right gluteus wound measured 8.4 cm in length, 4.1 cm in width, and not applicable for depth with a total surface area of 24.8 cm2. - On 01/07/2025 Resident #111's right gluteus wound measured 4.8 cm in length, 1.6 cm in width and not applicable to depth with a total surface area of 6.4 cm2. - On 12/17/2024 Resident #111's coccyx wound measured 2.3 cm in length, 1.0 cm in width, and not applicable for depth with a total surface area of 1.8 cm2. - On 12/31/2024 Resident #111's coccyx wound measured 2.1 cm in length, 1.1 cm in width, and 5.0 cm in depth, tunneling at 4.0 cm with a total surface area of 1.8 cm2. - On 01/07/2025 Resident #111's coccyx wound measured 2.0 cm in length, 0.7 cm in width, 1.5 cm in depth and 2.7 cm in tunneling with a total surface area of 1.3 cm2. Review of Resident #111's skin checks weekly and prn-V3 dated 12/06/2024 showed in Question 2 Actions marked: No new areas of skin impairment. On 1/08/2025 at 10:42 a.m., an interview was conducted with Staff A, LPN/UM. Staff A, LPN/UM stated Resident #111 arrived back to the facility with his known right heel skin condition, but the skin check done upon his arrival 11/27/2024 was updated by her to include a skin tear to Resident #111's right gluteal area. Staff A, LPN/UM also stated per her note, the resident had bruising to the upper bilateral arms and abdomen, skin discoloration to the back of his hands, bilateral dry feet, dried blister to his right heel, skin immobilizer to his left lower extremity with intact skin, right blanchable buttocks, and a nickel size tear to his right gluteus. Staff A, LPN/UM stated the ADON added an additional assessment/note stating the resident had a left heel calloused area and shearing to left gluteus. Staff A, LPN, UM stated the treatment plan was Betadine to right heel every shift. On 01/08/2025 at 12:42 p.m., an interview was conducted with the DON and the ADON. The DON showed a work delivery order for an air mattress dated 12/17/2024. When asked about wound rounds for 12/24/2024 and the lack of an entry for the wounds for Residents #89 and #111, the DON stated all higher-level nursing staff were all working on this day because all nurses were inadvertently given the day off, stating, I know we did wound care because all four of us were there on carts. 105553 Page 9 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a facility policy titled Wound Prevention and Treatment Overview, effective October 2021, showed the Policy Statement: The facility strives to ensure that a resident/patient entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements the following interventions to prevent the development of pressure ulcers: - Identify residents /patients at risk and the specific factors placing them at risk then implement an individualized plan of care based on the identified factors - Reduced occurrence of pressure over Bony prominences to minimize injury - Protect against the adverse effects of external mechanical forces (pressure, friction, shear). - Increase the awareness of ulcer prevention through educational programs The facility also recognizes the most vigilant nursing care may not prevent the development and/or worsening of ulcers in high -risk categories. In those cases, efforts will be directed at the following: - Managing risk factors - Providing therapeutic intervention - Providing treatment The facility has developed prevention and treatment protocols based on National Pressure Ulcer Advisory Panel (NPUAP) and Wound, Ostomy and Continence Nurses Society (WOCN). A resident with ulcers will receive continued prevention interventions and necessary treatment and services to promote healing and prevent infection. Wound characteristics will be documented by measuring length, width and depth in centimeters. Additional documentation shall also include color of drainage, wound bed color, odor, amount of drainage, wound bed tissue type and tunneling undermining with depth if applicable. The policy also showed the following Procedures: 1. Collect data on residence patients at admission to determine risk for developing pressure ulcers and identifying risk factors: a. admission data collection and initial plan of care. b. Nutrition risk data collection and assessment. Wound Prevention and Treatment Overview 2. Implement the initial plan of care. a. admission data collection and initial plan of care. 3. Include the resident patient and or responsible party education. 105553 Page 10 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0686 a. Develop an individualized plan of care based on risk factors, presence of ulcers and Braden Risk or Norton Plus Risk Score (state specific). Level of Harm - Minimal harm or potential for actual harm 4. Communicate interventions to staff. Residents Affected - Few 5. Review and revise plan of care as needed. 6. Provide resident/ patient and or responsible party education. 7. Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition. 105553 Page 11 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility did not ensure a Peripherally Inserted Central Catheter (PICC) was maintained based upon current professional standards of practice for one (#106) out of three residents sampled. Residents Affected - Few Findings included: On 01/05/2025 at 1:16 p.m. an observation was made of Resident #106 in her room with enteral tube feedings infusing. Resident #106 lifted her left arm to where a PICC line was observed. Further observation showed the catheter dressing dated 12/21/24. Staff K, Certified Nursing Assistant (CNA) made observation of the PICC line date and confirmed the date was 12/21/24. On 01/08/2025 at 10:28 a.m. an interview was conducted with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff A, LPN/UM confirmed no physician orders were provided in the care of Resident #106s PICC line. Staff A, LPN/UM stated usually when a resident has an order for a PICC line, a standard built in order set for central line catheter will be added as an order to ensure PICC line catheter and dressing assessments and dressing changes. Staff A, LPN/UM stated the dressing should have been changed every seven days per their protocol and assessed per shift by the nursing staff. Review of current physician orders for Resident #106 showed the following: -May insert Mid-line with 1% Lidocaine for antibiotic ordered on 12/21/2024. -Rocephin solution reconstituted use one gram intravenously one time a day for infection for seven days ordered on 12/17/2024, started on 12/18/2024 and completed on 12/24/2024. Review of the facility's policy and procedures titled, Vascular Access Devices and Infusion Therapy Procedures, dated 10/2024 showed a purpose statement: To prevent local and systemic infection to the IV (intravenous) catheter. The policy statement showed a sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular device securement. 2. Short peripheral catheter dressings are changed every seven days or when the integrity of the dressing is compromised. Change the dressing if moisture, drainage or blood is present or for further assessment if infection is suspected. 3. Central venous access device and peripheral midline dressings are changed every seven days and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. - Transparent semi permeable membrane dressings are changed every seven days and PRN - If a Chlorhexidine impregnated gauze sponge is applied under the transparent dressing, change every seven days. Photographic evidence obtained. 105553 Page 12 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed, and six errors were identified for one resident (#88) of five residents observed. These errors constituted a 23.08% medication error rate. Residents Affected - Few Findings included: On 01/07/2025 at 8:49 a.m., an observation was made of Staff F, Registered Nurse (RN) administering the following medications for Resident #88: -Glargine 10 units Subcutaneously -Biktarvy 50 milligrams/200 milligrams/25 milligrams oral tablet dispensed one tablet -Metoprolol 25 milligrams oral tablet dispensed one tablet -Paroxetine HCL 10 milligrams oral tablet dispensed two tablets -Famotidine 20 milligrams oral tablet dispensed one tablet -Aspirin 81 milligrams oral tablet dispensed one tablet -Prebiotic oral tablet dispensed one tablet -MiraLAX 17 grams dispensed one capful per manufacturer's -Breo 100 micrograms/25 micrograms inhaler provided one puff All medications were crushed, mixed in apple sauce and administer to Resident #88. Resident #88 refused her MiraLax. A review of the physician orders for Resident #88 showed the following: -Bictefravir-Emtricitab-Tenofox oral tablet 50-200-25 milligrams (mg) give one tablet by mouth one time a day for human immunodeficiency virus. -Acidophilus tablet (Lactobacillus), give one tablet by mouth one time a day for GI (gastrointestinal) upset OTC (over the counter) medication provided by the facility. -Aspirin oral capsule 81 mg give one capsule aby mouth one time a day for clot prevention. -Famotidine oral tablet 20 mg, give one tablet my mouth two times a day for (Gastroesophageal reflux disease). -Metoprolol tartrate oral tablet 25 mg, give one tablet by mouth two times a day for (hypertension). 105553 Page 13 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0759 -Paroxetine HCL (hydrochloride) oral tablet 10 mg, give two tablets by mouth one time a day for depression. Level of Harm - Minimal harm or potential for actual harm No physician orders to crush the above medications were noted. Residents Affected - Few On 01/08/2025 at 9:17 a.m. a telephone interview was conducted with the facility's consultant pharmacist. The consultant pharmacist stated there should be an order from the physician to crush medications. The pharmacist stated the literature he researched for Biktarvy initially stated medication should not be crushed; however, other literature suggested the medication could be dissolved in water. On 01/08/2025 at 10:28 a.m. an interview was conducted with Staff A, Licensed Practical Nurse/Unit Manager (LPN/UM). Staff A, LPN/UM stated nursing staff will administer medication according to the needs of the resident. Staff A, LPN/UM further stated there should be a physician order to crush medications. Staff A, LPN/UM reviewed Resident #88's physician orders and could not find an order to crush medications. On 01/08/2025 at 1:31 p.m. an interview was conducted with Staff I , LPN. Staff I, LPN stated she would never crush a medication without a physician order. On /1/08/2025 at 2:26 p.m. an interview was conducted the Assistant Director of Nursing (ADON). The ADON stated there should be a physician order to crush medications. On 01/08/2025 at 2:30 p.m. an interview was conducted with Staff F, RN. Staff F, RN stated she would look at the resident's diet status and the resident's preference to determine how to administer medications. Staff F, RN stated she knows not to crush certain medications like Potassium and Nifedipine. Staff F, RN did not know the crushing status of Biktarvy. On 01/08/2025 at 2:37 p.m. an interview was conducted with Staff J, RN. Staff J, RN stated she would obtain an order from the physician to crush medications. On 01/08/2025 at 2:47 p.m. an interview was conducted with Staff H, LPN. Staff H, LPN stated she would get an order to crush medications. Review of a facility policy titled Medication Administration - General Guidelines, dated 09/2018 showed the following policy statement: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Preparation: 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and storage schedule on the resident's MAR with the medication label. If the label and MAR are different, and the container is not flagged indicating a change in directions, or if there is any other reason to question the doses or directions, the prescribers' orders are checked for the correct dosage schedule. Apply a direction change sticker to label if directions have changed from the current label. 105553 Page 14 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5. if it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube -fed, using the following guidelines and with a specific order from prescriber. a. The need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regimen Reviews. 105553 Page 15 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure drugs and biologicals were securely stored in four resident rooms (211-B, 212-A, 212-B, 501-B, and 611-B) of 62 rooms and for one (700 hall cart) of three medication carts used in the facility. Findings included: An observation on [DATE] at 10:07 a.m. in room [ROOM NUMBER]-A showed an 8-ounce (oz) spray bottle of dermal wound cleanser laid on the nightstand at bedside. An observation on [DATE] at 10:17 a.m. in room [ROOM NUMBER]-B showed a 3.75 ounce (oz) of antifungal cream laid on the nightstand at bedside. An observation on [DATE] at 10:25 a.m. in room [ROOM NUMBER]-B showed a 2.5-ounce (oz) [Manufacture's name] hydrophilic wound dressing cream and two 18-ounce (oz) packets of preventative ointment laid on the nightstand at bedside. During an interview on [DATE] at 5:03 p.m. the Assistant Director of Nursing (ADON) and designated Infection Preventionist (IP) stated the 8-ounce (oz) spray bottle of dermal wound cleanser found in room [ROOM NUMBER]-A should not be left or stored at bedside and should be appropriately stored in the treatment cart. The ADON/IP stated the antifungal cream found in room [ROOM NUMBER]-B, although not supplied by the facility, should not have been stored at bedside. The ADON/IP stated as far as room [ROOM NUMBER]-B the hydrophilic wound dressing cream, also not supplied by the facility, should not have been stored at bedside and the two 18-ounce (oz) packets of preventative ointment are usually carried in the pockets of the Certified Nursing Assistants (CNA) and should not have been left at bedside. 3. On [DATE] at 2:30 p.m. an observation and interview were conducted with Resident in room [ROOM NUMBER]-B. Resident was noted with loose eye drop medications in a small plastic bowl. The resident stated those were his eye drops. On [DATE] at 9: 35 a.m., an observation was made of the resident in 611-B bed asleep with his eye drops on his bedside table in the plastic bowl. On [DATE] at 12:00 p.m. the resident in 611-B was observed with his eye drops on the bedside table in a plastic bowl. On [DATE] at 1:20 p.m., an observation was made of the medication cart on the 700 hallways with Staff R, Registered Nurse/Unit Manager (RN/UM). Six loose pills were found in medication drawers and one expired insulin pen. Staff R, RN/UM stated the insulin pen was from a resident who was discharged and removed the pen. Staff R, RN/UM stated she tries to clean the cart at least once every two weeks but ultimately it falls on the nursing staff responsible for the cart. On [DATE] at 11:45 a.m. an interview was conducted with the Director of Nursing (DON) regarding findings of loose pills in the medication cart in 700 hallway and unsecured medication in room [ROOM 105553 Page 16 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some NUMBER]-B. The DON stated the resident in 611-B normally stays in his room all day and is very good about putting his medication away when he leaves for therapy. This resident had physician orders for self-administration. On [DATE] at 1:10 p.m., an observation was made in room [ROOM NUMBER]-B. The resident in 611-B was not present in his room. The eye drops remained on his bedside table in the plastic bowl unsecured. Review of the Facility's Policy Storage of Medications dated 09/2018 showed, Policy: Medications and biologicals are stored properly, following manufacture's or providers pharmacy recommendations, to maintain their integrity and to support safe and effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. Review of a facility policy titled, Medication Administration Self - Administration by Resident, dated 11/17, showed a policy statement: Residents who desire to self-administer medications are permitted to do so with the prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration. 7. If the interdisciplinary team determines that bedside or in- room storage of medications would be a potential safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room. The medication nurse will provide the medication to the resident in the unopened package, when appropriate, for the resident to self-administer. The nurse then records such self-administration on the MAR in the manner described above. 1. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 14. Outdated, contaminated, discontinued or deteriorated medication and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal 15. Medication storage should be kept clean, well lit, organized and free of clutter. (Photographic Evidence Obtained). 2. On [DATE] at 10:011 a.m., at 12:00 p.m. and at 1:15 p.m., an observation was made of Ammonium Lactate Cream 12% laid on the dresser at bedside in room [ROOM NUMBER] - B. During an interview on [DATE] at 10:11 a.m. the resident in room [ROOM NUMBER]-B stated the staff put the medicated lotion at his bedside for him or for the staff to administer. An interview was conducted on [DATE] at 5:01 p.m. with the Assistant Director of Nursing (ADON). The ADON stated Ammonium Lactate Cream 12% should not be at the resident's bedside without a physician's order for self-administration. 105553 Page 17 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure nebulizer masks for three residents (#9, #92 and #221) out of 16 residents identified with nebulizer treatment orders were stored in a safe and sanitary manner. The facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) for one resident (#112) of 17 residents identified with GI (Gastronomy) tubes while care was provided. Residents Affected - Few Findings included: An observation on 01/05/25 at 9:15 a.m. showed Resident #221's nebulizer mask laid on top of the provided respiratory storage bag at bedside. During an interview on 01/05/25 at 9:15 a.m. Resident # 221 stated he was administered nebulizer treatments for about 15 minutes before bed nightly. Review of the admission record showed Resident #221 was admitted to the facility on [DATE] with diagnoses that included but not limited to Pleural Effusion, not elsewhere classified and heart failure. Review of current physician orders for Resident #221 showed, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) {milligrams] MG/3 [milliliters] ML (Ipratropium-Albuterol)- 3 milliliter inhale orally every 6 hours for Shortness of Breath. Order date 12/19/24. An observation on 01/05/25 at 9:33 a.m. showed Resident #9's nebulizer mask laid on top of the provided respiratory storage bag at bedside. During an interview on 01/05/24 at 9:33 a.m. Resident # 9 stated he was administered nebulizer treatments daily. Review of the admission record showed Resident #9 was admitted to the facility on [DATE] with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD). Review of current physician orders showed, Albuterol Sulfate Nebulization Solution (2.5 [milligrams] MG/3 [milliliters] ML) 0.083% (order date 03/08/24) 1 vial inhale orally via nebulizer two times a day related to Respiratory failure unspecified with hypoxia. Pre-Evaluation: Describe Lung Sounds (CL-clear, D-diminished, R-rales, RH-rhonchi, W-wheezing) Change nebulizer set up and tubing every week- every night shift every Wed Label tubing with date when changed and As needed Label tubing with date when changed. Order date 03/08/24. An observation on 01/05/25 at 11:40 a.m. showed Resident #92's nebulizer mask laid on top of the provided respiratory storage bag at bedside. During an interview on 01/05/25 at 11:40 a.m. Resident #92 stated that she received nebulizer treatments daily. Review of the admission record showed Resident #92 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease (COPD) and 105553 Page 18 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0880 simple chronic bronchitis. Level of Harm - Minimal harm or potential for actual harm Review of current physician orders showed Budesonide Inhalation Suspension 0.5 [milligrams] MG/2[milliliters] ML (Budesonide(Inhalation)) 2 ML inhale orally two times a day for [shortness of breath] SOB. Order dated 11/06/24. Residents Affected - Few During an interview on 01/07/25 at 5:03 p.m., the Assistant Director of Nursing (ADON) and designated Infection Preventionist (IP) stated all nebulizer masks, when not in use, should be stored in the provided respiratory storage bag for proper infection control practices. During an interview on 01/08/25 at 10:50 a.m., the ADON/IP stated any staff who were assisting with care of a Resident who had a Gastronomy (G) Tube should be wearing a gown and gloves as resident's with G Tubes would be under Enhanced Barrier Precautions. 2. On 01/07/2025 at 12:00 p.m. an observation was made of Staff G, Licensed Practical Nurse (LPN) during a medication administration of a resident with a medication to be administered via gastrostomy tube. Staff G, LPN did not wear a gown during the administration. A review of Resident #112's physician orders showed an order for Gabapentin 300 milligram one capsule via G-tube (gastrostomy tube) three times a day for neuropathy. Review of the facility's policy Barrier Precautions dated April 2024 showed, Enhanced Precautions- refers to an infection control interventions designed to reduce transmission or multi-drug-resistant organism that employ targeted gown and glove use during high contact resident activities. Review of the facility's policy Medication Administration via Nebulizer dated January 2020 showed, Procedure: 14. Store the dry nebulizer in a 'Storage bag' labeled with resident name and date. (Photographic evidence obtained). 105553 Page 19 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, facility record review and staff interviews, the facility failed to ensure one of one kitchen dish washing machine was maintained and operated per the manufacturer's specifications related to wash cycle temperatures running below operation requirements. Residents Affected - Many Findings included: On 1/5/2025 at 9:20 a.m. a kitchen tour was conducted with Staff N, Dietary Aide. He was observed operating the dish washing machine. Staff N stated he began washing dishes about ten minutes earlier, which would have been around 9:10 a.m. Staff N pushed a crate of dishes through the left side of the machine to be washed. The right side of the machine was observed with three crates of already washed dishes. Staff N revealed he believed the machine was operating at the required wash and rinse temperatures. He stated he had ran over ten crates of dishes during that time frame. Staff N did not know what the required wash and rinse temperatures were. On 1/5/2025 at 9:58 a.m. the Dietary Manager provided a full kitchen tour. The Dietary Manager revealed they operate a high temperature dish washing machine and the wash cycle temperature should reach at least 160 degrees F. (Fahrenheit), and the final rinse temperature should reach 180 degrees F. She provided the last two months (12/2024 and 1/2025) of the dish machine temperature log for review. Review of the log revealed there were several dates of temperatures testing that were not documented. The Dietary Manager stated the missing dates were prior to her working at the facility and that she had been the Dietary Manager for about three weeks. During the on-going tour and observation of the dish washing room, Staff N and Staff O, Dietary Aides were observed operating the dish machine and feeding it crates of soiled dishes. Staff N was feeding soiled crates of dishes into the machine and then receiving clean crates of dishes on the other side of the machine. An interview was conducted with Staff N and Staff O. Staff O stated the machine was a high temperature machine. He stated, The wash temperature should reach 164 degrees F, and the rinse temperature should reach 180 degrees F. The Dietary Manager cued Staff O with the correct wash and rinse temperatures. Staff O then stated the wash cycle was supposed to be a minimum of 160 degrees F., and not 164 degrees F. Staff N did not respond with an answer to the requirements of the dish washing temperatures. Review of the machine's specification plate revealed the machine is to be operated as a high temperature machine with requirements of wash cycle reaching 160 degrees F., and a rinse cycle reaching 180 degrees F. On 1/5/2025 at 10:01 a.m. Staff N was observed running an empty crate through the soiled side of the machine and it ran though it's cleaning cycle. The analog thermometer attached to the machine revealed the wash cycle reached 152 degrees F., before the rinse cycle began. Once the rinse cycle ran, the rinse temperature reached 185 degrees F. The Dietary Manager confirmed the wash temperature did not meet expectation the machine's requirement. During a second dish washing observation at 10:04 a.m. Staff N ran a full crate of soiled dishes through the soiled side of the machine. The thermometer revealed the wash cycle reached 150 degrees F and the rinse cycle reached 189 degrees F. The Dietary Manager confirmed the wash temperature did not meet expectation the machine's requirement. 105553 Page 20 of 21 105553 01/08/2025 Carrollwood Care Center 15002 Hutchinson Rd Tampa, FL 33625

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 1/5/2025 at10:08 a.m. a third machine operation demonstration was observed. Staff N ran an empty crate through the soiled side of the machine. During this observation, the wash cycle reached 152 degrees F, and the rinse temperature reached 186 degrees F. The Dietary Manager confirmed the Wash temperature did not meet the washing machine's requirement. On 1/5/2025 at 10:11 a.m. a fourth demonstration was conducted with the Dietary Manager who pushed an empty crate through the soiled side of the machine. The wash cycle reached 150 degrees F., before the rinse cycle began, reaching a rinse temperature of 188 degrees F. The Dietary Manager confirmed the wash temperature did not meet the dish washing machine's requirement. After four separate demonstrations for the use of the machine, it was found the wash cycle did not meet minimum requirements of 160 degrees F.; and only reaching 152 degrees F., 150 degrees F., 152 degrees F., and 150 degrees F. The observations revealed Staff N had ran the machine and washed over ten crates of dishes while the wash temperature was below the temperature requirements. On 1/5/2025 at 1:45 p.m. the Dietary Manager stated the dish machine's service maintenance person was in the building and found the thermostat for the wash temperature needed a part replaced as well as it needed a temperature water flow adjustment. On 1/8/2025 at 10:00 a.m. the Dietary Manager provided the Dish Machine's Manufacturer Operation Manual for review. The table of contents section of the manual in section II revealed, Installation/Operation Instructions on page 40 - the machine is a High Temperature machine and operates with hot water sanitizing and requires wash cycle to reach 160 degrees F., and rinse cycle to reach 180 degrees F., in order to appropriately and effectively wash dishes. Review of a facility policy with an effective date of 6/2024, titled, Dish Machine revealed a policy to monitor dish machine temperatures for high temperature machine at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. The procedure section of the policy revealed: 1.) Record the type of machine (High Temp or Low Temp) at the top of the Dish machine Log. Fill the appropriate wash, rinse and final rinse temperature for the appropriate dish machine type. 4.) Send an empty dish rack through the dish machine prior to recording temperature. a. This allows the water to reach appropriate temperatures. b. May take 3-4 times. 5.) Record wash and rinse temperatures under appropriate meal column and initial. 7.) Report discrepancies from standard temperatures and chemical saturation to the Food Service Manager immediately. (Photographic Evidence Obtained). 105553 Page 21 of 21