Health inspection·October 28, 2022

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Advised: Yes; Type of Grievance: Staff; Final Disposition: Resolved. On 12/16/21, the daughter reported that staff informed her mother to urinate in the incontinent brief if the staff does not get to her in time. Actions Taken: Staff educated to attend patient's needs in a timely manner and toilet patient as requested. Complainant Advised: Yes; Type of Grievance: Other; Final Disposition: Resolved. On 12/17/21, the daughter reports her mom has been without oxygen for 8 hours and the order is continuous. Daughter wants to ensure that labs are monitored regarding sodium and that they were supposed to be drawn in the AM; Actions Taken: Administration spoke with daughter the same evening. Resident placed on every 2-hour rounds to ensure O2 (oxygen) is on and response to needs. Labs should be back tomorrow AM. Results informed; Complainant Advised: Yes; Type of Grievance: Other; Final Disposition: Resolved. Interview and record review with the Regional Director of Social Services on 10/28/22 at 10:18 AM, revealed that on the Concern/Grievance Form the section for the complainant advised of result and the resolution acceptable to the complainant was blank and not filled out for 12/14/21, 12/16/21 and 12/17/21. She stated, It was not documented that the daughter accepted what was done. She acknowledged the daughter should have been made aware of the grievance resolutions and sections should have been filled out. During an interview with the Administrator on 10/28/22 at 1:29 PM. She revealed that the resolution information is not documented on the grievance forms, and it should be, and the complainant should have been informed of the results of the grievance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 2 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, record review and interview, facility failed to follow the menu for pureed diets for the evening meal on 10/26/22. There were 79 residents who were served pureed diets in the facility. Residents Affected - Some Findings included: On 10/26/22 at 4:21 PM, observation revealed there was a pan of pureed pasta and a pan of pureed beef held stored on the steam table for the evening meal. Review of the facility Week 6, Day 4 menu indicated 6 ounces (oz). pureed beef and macaroni were to be served for the evening meal for pureed diets (the menu did not indicate that the beef and macaroni was to be served separately). The Director of Food and Nutrition Services stated that they made the pureed beef and pureed macaroni separately, because some residents do not like macaroni. The surveyor asked to see the recipe, and the evening Food and Nutrition Services supervisor, Staff A (contract food service staff) could not find the recipe in the recipe book. She stated that they serve 3 oz. of pureed macaroni and 3 oz. of pureed beef. The Director of Food and Nutrition Services provided a recipe for beef, macaroni, and tomatoes for regular consistency diets; however, the recipe did not include instructions on how to prepare the pureed beef and macaroni. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 3 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interviews, the facility failed to ensure that clean equipment was protected from contamination; clean eating utensils were stored to prevent contamination; Time/Temperature for Safety (TCS) foods were held at proper temperature; and equipment was properly sanitized. This has the potential to affect 179 residents out of 195 residents who consume the facility's food. Findings included: During a follow up visit to the kitchen on 10/26/22 at 4:21 PM, there was a caddy of eating utensils, containing forks and spoons that were stored with their handles down (photographic evidence obtained). Staff would have to touch the lip- or food-contact surface of the eating utensil to remove them from the caddy. The Director of Food and Nutrition Services (contract food service staff) stated that the Food and Nutrition staff use these utensils when they need for the tray line service. The Director of Food and Nutrition Services said these utensils should be stored handle side up. On 10/26/22 at 4:34 PM, a black insulated jacket (used for the walk-in freezer) was stored near clean equipment in food preparation area on the table with the stand mixer. Photographic evidence obtained. At 4:30 PM, on 10/26/22, the underside surface of the shelf over a steam table was coated with a brown substance (Photographic evidence obtained). The Director of Food and Nutrition Services observed the shelf in this condition. The surveyor asked for the equipment cleaning schedule. The equipment cleaning schedule was provided on 10/27/22 and it showed that the supervisor was supposed to clean the tray line after each use. Interview with the Director of Food and Nutrition Services on 10/28/22 at 8:22 AM, confirmed that the supervisor is supposed to clean shelf on the steam table as part of the cleaning the tray line after each use. During the beginning of the evening meal service on 10/26/22 at 4:44 PM, the surveyor asked about the scope sizes being used for the pureed beef and macaroni. One of the cooks had removed them and put them at the 3 compartment sink to be washed. The porter, Staff B (contract food service staff), who was manually washing dishes at the three-compartment sink, cleaned the scoops very quickly in soapy water; rinsed the scoops quickly under running water from the faucet; then dipped them in the sanitizer solution; and finally put them on the drain board. He did this twice. The scoops were not immersed for at least 30 seconds in the quaternary ammonium sanitizer solution to properly sanitize them. The porter, Staff B spoke Spanish and one of the cooks translated from English to tell him that he must leave the scoops in the sanitizing solution for at least 30 seconds. The porter Staff B still did not understand, so the cook had to explain it again and he understood. The surveyor asked the porter, Staff B if he could demonstrate testing the sanitizer level in the 3-compartment sink, and he said in basic English words that he does not speak English (his primary language was Spanish) and did not know how to test the sanitizer level (the surveyor knew basic Spanish). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 4 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/26/22 at 4:49 PM, the Food and Nutrition Services staff were taking holding temperatures of the hot food on the steam table before the evening meal. The holding temperature of the pureed beef was 124 degrees Fahrenheit (F). The host foods on the steam table were well ranged from 140 to 191 degrees F. The evening cook, Staff C (contract food service staff) took the temperatures of the pureed beef several times, and stirred the pureed beef, but the food temperature did not reach the minimum of 135 degrees F. She used a different digital thermometer to check the temperature and the pureed beef temperature was not above 126 degrees F. The surveyor asked the evening cook, Staff C what was the minimum temperature she was looking for and she replied 160 [degrees F]. The Director of Food and Nutrition Services came along and said, you know what to do - you take it out and reheat it. You're allowed mistakes. The surveyor asked evening cook, Staff C if she checked the final internal cooking temperature of the pureed beef and she said she did but didn't record it. She stated that the pureed beef was 170 degrees F when she finished cooking it. The evening cook, Staff C removed the pan of pureed beef from the steam table to reheat the food. At 5:07 PM, the evening Food and Nutrition Services supervisor, Staff A (contracted food services staff) was taking the holding temperatures of the cold food. She had a digital thermometer in a cup of ice water. It initially read 33 degrees F (rather than 32 degrees F). The surveyor advised Staff A that the cup needed more ice. She added more ice and the digital thermometer read 30 F. The surveyor asked the Staff A what temperature she was looking for when checking the accuracy of the thermometer and she was not able to say that it was supposed to be 32 degrees F. Review of the HACCP (Hazard Analysis and Critical Control Point) Critical Control Points Daily Temperature Log for the evening meal of 10/26/22, the Food and Nutrition Services staff were recording the hot and cold holding temperatures under the section for Cooking Internal Temperatures on the temperature log, rather recording them in the section on the log for Holding Temperatures (Photographic evidence obtained). The Food and Nutrition Services staff were not recording any internal cooking temperatures of hot food on the log for the month of October 2022. The Director of Food and Nutrition Services was made aware of this at the time. The evening cook, Staff C did not record the reheating temperature of the pureed beef on the temperature log for 10/26/22, and there was a section on the temperature log for recording reheated food. The Food and Nutrition Services staff were also not recording cooling temperatures of food on the temperature log for the month of October 2022. During the evening meal service on 10/26/22 at 5:29 PM, the surveyor observed a pan of pureed bread on a counter next to the steam table. The pureed bread was not on a heat or cold source to control the temperature of the food. The surveyor asked the Director of Food and Nutrition Services if the pureed bread should be hot or cold. The Director of Food and Nutrition Services said that it felt cold to him when he touched the side of the pan with his hand. The surveyor touched the side of the pan of pureed bread as well, and it was not cold like 41-degree F. The surveyor asked the Director of Food and Nutrition Services if the pureed bread was a TCS (Time/Temperatures Control for Safety) food (a food that requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth or toxin formation) and he said he thought it was. The pureed bread was not under temperature control and the facility was not using time instead of temperature for public health control. The surveyor asked the Director of Food and Nutrition Services how the pureed bread was made. He said it was made with bread, water, and a thickener. The surveyor asked what bread was used for the pureed bread and the Director of Food and Nutrition Services said whole wheat bread. The surveyor and the Director of Food and Nutrition Services looked at the ingredient label on the commercially prepared fresh loaf bread package. The pan of pureed bread remained on the counter. The surveyor requested a recipe for the pureed bread. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 5 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The Director of Food and Nutrition Services provided a recipe for the pureed bread on 10/27/22. However, the pureed bread recipe doesn't match the observed pureed bread product and the Director of Food and Nutrition Services' description of the pureed bread preparation. The pureed bread recipe called for a commercially manufactured pureed bread mix. On 10/28/22 at 8:13 AM, the Director of Food and Nutrition Services said they use the recipe but use fresh bread rather than a commercial pureed bread mix. The surveyor told the Director of Food and Nutrition Services that the commercially manufactured pureed bread mix might be formulated to ensure the product was not a TCS food when made, so it did not require temperature control. The Director of Food and Nutrition Services provided a copy on 10/27/22 of the Food and Nutrition Services staff in-service training for sanitizing/dish machine/3 compartment sink, which was completed on 9/30/22. On 10/28/22 at 8:21 AM, the Director of Food and Nutrition Services and the head Chef (contract food services staff) indicated that the porter, Staff B's signature was not included in the sign-in sheet for the in-service training conducted on the three-compartment sink on 09/30/22. The contracted porter, Staff B was hired on 2/08/22. The contract food service Food Safety Policies and Procedures, revised on 4/01/22 included the following: Section C - FDA Food Code, Chapter 3, C - 23 Cooling and Chilling - . Cooling and chilling temperatures must be taken with a calibrated thermometer and recorded on the HACCP Cooling and Chilling log. Section C - FDA Food Code, Chapter 3, C - 24 Hot and Cold Holding - . Cold foods must be held and served at a temperature of 40 degrees F (4 degrees Celsius) or below [The FDA Food Code standard is TCS cold food must be held at 41 degrees F or below] . Hot foods must be held and served at a temperature of 140 degrees F (60 degrees Celsius) or above [The FDA Food Code standard is TCS hot food must be held at 135 degrees F or above . Hot and Cold food service temperatures must be taken with a calibrated thermometer and record on the HACCP log . Temperatures must be taken and recorded at the time of service set up and at a minimum once every two hours during service. If service time is less than two hours a final hold temperature must be recorded if the food is not discarded. Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 3, Food and Equipment Temperature Measuring Devices - . Accurate food and equipment thermometers (cleaned, sanitized, and calibrated) are available and used by all food employees during storage, preparation, display, service and transportation . Thermometers must be accurate to at least +/- 2 degrees F from 32 degrees F (+/- 0.5 degrees Celsius from 0 degrees Celsius) . Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 8, Cleaning and Sanitizing Food Contact Surfaces - .Washing, rinsing, and sanitizing procedures must be posted and adhered to at all manual and mechanical ware washing equipment in use . Contact time with chemical sanitizer solution must meet manufacturer's instructions including water temperature requirements . Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D-9, Cleaning and Sanitizing Frequency . Nonfood contact surfaces must be cleaned at a frequency necessary to preclude accumulation of soil residues . A cleaning schedule must be created and utilized. Identifying what is to be cleaned, frequency, and what equipment/cleaning agents . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 6 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 10, Storage of Soiled Linens, Clean Equipment, and Utensils - . Clean equipment, utensils, and linens must be stored in a clean, dry location, where they are not exposed to splash, dust, or other contamination and at least 6 inches off the floor. Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 11, Kitchen and Tableware - . Single service and cleaned/sanitized utensils must be handled, displayed, and dispensed so the contamination of food and lip contact surfaces is prevented . Event ID: Facility ID: 105560 If continuation sheet Page 7 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action for correcting deficiencies resulting in repeated deficient practice. The facility was cited for Food Procurement, Store/Prepare/Serve-Sanitary (F 812) during the survey with exit date of 03/05/ 2020 and again on this recertification survey with exit date of 10/28/2022. This repeated deficient practice has the potential to affect any of the 191 residents residing in the facility at the time of the survey. The findings included: Record view of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) written by the Administrator and the reviewed date was on 8/22/2022, the policy documented: The facility will form a QAPI Steering Committee, designed to meet monthly. The committee must include the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist and at least two other members representing the facility staff. The primary objectives of Quality Assurance & Performance Improvement (QAPI) are to monitor, assess and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/health care errors on a continuous basis throughout the facility. Review of the Quality Assurance and Performance Improvement (QAA) Committee Meeting Sign-in Sheets dated 8/24/22, 9/21/22 and 10/19/22: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 10/28/22 at 1:33 PM, the Administrator stated, The QAA Committee meets monthly. Committee members are Administrator, Medical Director, DON, Department Heads, Pharmacy, Infection Control Preventionist and Contract Companies are in attendance. The purpose of QAA is for performance improvement, monitoring and evaluating opportunities of improvement. We look at satisfaction surveys, grievances, CASPER quality measures and any feedback from a family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 8 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, facility failed to ensure the kitchen dish machine was operating properly and maintaining the proper wash and rinse temperatures. There were 179 residents out of 195 residents who used the facility's eating utensils and dishes. Residents Affected - Some Findings included: A follow up visit to the kitchen was conducted on 10/27/22 at 2:33 PM to observe the mechanical dishwashing process. Dishwashing was in progress with a multi tank dish machine in use that used high temperature sanitization. The dish machine had three temperature gauges on the front of the machine. The temperatures on these gauges were: Wash temperature: 145 degrees Fahrenheit (F) Rinse temperatures: 158 F Final rinse temperature: 191 F The hot water pressure gauge was 20 PSI (pounds per square inch). The data specification plate on the dish machine documented the following minimum dish machine temperatures and water pressure: Wash temperature: 150 degrees F Rinse temperatures: 165 degrees F Final rinse temperature: 180 degrees F. Pressure: 20 to 25 PSI The surveyor informed the evening Food and Nutrition Services supervisor, Staff A (contract food service staff) about the wash and rinse temperatures that were not reaching the minimum required temperatures. Staff A took a photo of the gauges. The gauge temperatures were still not reaching the proper temperatures at 2:43 PM, as the wash temperature and rinse temperature were 149 degrees F and 158 degrees F, respectively (Photographic evidence obtained). There were two Food and Nutrition Services staff working the machine at each end of dish machine. The surveyor asked the porter working on the soiled end of the dish machine (Staff D, contract food service staff), how often he checks the temperatures on the machine. He stated a couple of times. He stated that the wash temperature was not reaching the minimum required temperature. At the same time, there was a pipe near the pressure gauge was that was leaking water. On 10/27/22 at 2:46 PM, a maintenance associate, Staff E arrived, and the surveyor told him about the leaking pipe. He was not aware of the leaking pipe. According to the Weekly High Temperature Mechanical Ware Washing Machine Log, the staff were recording the wash temperatures and final rinse temperatures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 9 of 10 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 105560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Annes Nursing Center, St Annes Residence Inc 11855 Quail Roost Drive Miami, FL 33177 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The staff were not recording the rinse temperature of the middle gauge, as there was no place on the form to record these temperatures. The temperatures were recorded to be above the minimum required temperatures for the wash and final rinse temperatures on the Weekly High Temperature Mechanical Ware Washing Machine Logs. The dishes were observed to be clean by sight after washing through the dish machine. At 2:47 PM, the surveyor informed the evening Food and Nutrition Services Supervisor, Staff A about the leaking pipe and the wash temperature that was not reaching 150 degrees F, as it was 145 degrees F at the time. On 10/28/22 at 8:22 AM, the Director of Food and Nutrition Services (contract food service staff) stated that the leaking pipe was fixed. The contract food service Food Safety Policies and Procedures, revised on 4/01/22 included the following: Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 8, Cleaning and Sanitizing Food Contact Surfaces - .Washing, rinsing, and sanitizing procedures must be posted and adhered to at all manual and mechanical ware washing equipment in use . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105560 If continuation sheet Page 10 of 10