Inspection·April 4, 2024

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The facility's dish machine did not reach 120 degrees F during the rinse cycle, the walk-in freezer had a large accumulation of ice on the floor, on storage racks, and on food boxes, the kitchen ice machine was not working, and the freezer fan was not running. Residents Affected - Many The findings include: On 4/01/2024 at 12:51 pm, Dietary Aide C was asked to test the dish machine. She stated she was not really good at it. She stated Dietary Aide B usually performed this task. She then turned the dish machine on. At this time, none of the temperature gauges moved. She stated most of the time they tested the machine after lunch. She was not able to answer any questions regarding the dish machine. Signage was affixed to the wall behind the dish machine with operating instructions for the dish machine. Also, there was a label affixed to the machine advising that the minimum rinse temperature was 120 degrees. On 4/01/2024 at 1:03 pm, the certified dietary manager (CDM) returned to the kitchen. She was advised of the observation of the dish machine and that gauges weren't moving when the machine was turned on. She was asked to explain the process the facility used when the dish machine was inoperable. She stated Dietary Aide B repeated the process until the machine reached the appropriate temperature. She asked [NAME] D to test the dish machine. When he turned on the machine, neither of the gauges moved. The CDM stated, Yeah, it's off., adding that she would call Maintenance regarding the issue. The final rinse temperature gauge read 110 degrees Fahrenheit (F). On 4/01/2024 at 2:22 pm, the CDM advised that the gauges on the dish machine were set. She stated the only time they moved was if the temperature was less than 110 degrees F, as it was a low temperature machine. She advised that the dish machine was not broken as she previously stated. On 4/02/2024 at 11:21 am, the dish machine was re-tested. The Administrator, CDM, and Regional Dietary Manager were present. Again, neither of the gauges moved. The Administrator stated he received an email from the service company which stated the only gauge that should move was the final rinse. At this time, the Administrator, CDM, and the Regional CDM all confirmed that gauge did not move nor did any of the others. The CDM and Regional CDM stated the gauge would not move unless the water temperature dropped below 100 degrees F. They stated at that time that the gauge would slowly rise as the temperature increased. The Administrator advised them that was contrary to what the email from the service provider stated. He re-read the email aloud, emphasizing the final rinse temperature gauge was supposed to move. The Administrator then tapped on the final rinse temperature gauge with his finger. Again, the gauge did not move. The Regional CDM stated he would have to clarify this. The CDM (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105580 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 105580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton Shores Healthcare and Rehabilitation Cente 1350 S Nova Rd Daytona Beach, FL 32114 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)