Health inspection·August 3, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policies and procedures, the facility failed to cook raw unpasteurized eggs in a manner to destroy all viable Salmonella species bacteria, a virulent foodborne pathogen (disease-causing microorganism) that could cause food borne illness for 3 of 3 sampled residents, Residents #11, #334 and #335. Residents #11, #334 and #335 were over [AGE] years of age and were immunocompromised. Residents #11, #334 and #335 preferred undercooked eggs (over easy) for breakfast and were served unpasteurized shell eggs (that have not been specifically treated to destroy all viable Salmonella species bacteria). The findings included: The facility's policy, titled, Egg Preparation, most recently updated 02/2017, documented, in part, the following: Policy: when preparing eggs separately or as part of a recipe, only commercial Grade A or pasteurized egg products may be used. When preparing eggs to order only pasteurized eggs may be used. No raw eggs will be served. Procedure: 1. Examine all fresh eggs discarding any that are cracked or damaged. 2. Grade A raw egg may only be used in recipes where the egg will be cooked (i.e. pudding, cakes, quiche, etc. 3. Grade A raw eggs prepared separately must be cooked to at least 140 degrees for three minutes or 145 degrees for 15 seconds. This will yield a product in which the egg whites are completely set and the yolks are congealed. 4. All poached, over easy and other non-fully cooked egg menu items need to be prepared with pasteurized shell eggs. The facility's policy, titled, Cooked Egg Policy, most recently updated 04/2023, documented, in part, the following: To strive to protect residents from the potential for food-borne illness, all residents will be served eggs that have been cooked to the recommended internal temperature according to the Food and Page 1 of 5 105593 105593 08/03/2023 Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966

F 0812 Drug Administration. Level of Harm - Minimal harm or potential for actual harm Procedure: Residents Affected - Many 1. All residents will be served eggs that have been cooked to the recommended internal temperature of 145F, based on federal guidelines. 2. Pasteurized eggs will be used for preparations that will not meet the internal temperature of 145F, such as over-easy or poached eggs. The facility's menus that the residents fill out for their choices for breakfast offered Eggs Made to Order: Scrambled / Over Easy / Fried every day for breakfast. 1. Resident #11, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Post Polio syndrome, Personal History of COVID 19 (Coronavirus Disease 2019), Carcinoma (cancer) of skin, scalp and neck, Major depressive disorder, Acute embolism (blockage in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (the formation or presence of a blood clot within a blood vessel which can block or limit blood flow) of right lower extremity, Atherosclerotic heart disease of the native coronary artery (hardening of the arteries due to gradual plaque buildup) without angina pectoris (chest pain or pressure), Hypertension, Paroxysmal Atrial Fibrillation (an irregular and often very rapid heart rhythm), Hyperlipidemia (high blood cholesterol), Atherosclerosis (a buildup of fats, cholesterol and other substances in and on the artery wall that causes arteries to narrow blocking blood flow), Anemia, Malignant Neoplasm (cancer) of the pancreas, Diaphragmatic Hernia, Disorders of Plasma protein Metabolism (inherited metabolic disorders that involve malfunction of metabolism of proteins in the blood), and Gastroesophageal Reflux Disease (GERD). Review of physician orders revealed Resident #11 had orders that included: Pantoprazole Sodium Tablet Delayed Release 40 MG - for GERD. Review of the Annual Minimum Data Set (MDS) assessment documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. 2. Resident #334, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles, which can cause fatigue and shortness of breath upon exertion and fluid retention), Hypertension, Diabetes Mellitus, Alzheimer's disease, Non Alzheimer's dementia, Depression, Deep vein thrombosis of right lower extremity, Multinodular goiter (a condition where the thyroid gland is enlarged due to multiple lumps that can grow on more than one part of the gland), Atrial fibrillation, Rheumatoid Arthritis (a chronic inflammatory disease that affects the joints that results in painful joints, swelling and stiffness in the joint), and Osteoarthritis (degenerative joint disease). Review of the quarterly MDS assessment, dated 06/08/23, documented Resident #334 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. 3. Resident #335, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Idiopathic peripheral autonomic Neuropathy (a condition in which the nerves located outside of the brain and spinal cord are damaged causing weakness, numbness, and 105593 Page 2 of 5 105593 08/03/2023 Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many pain), history of COVID 19 (Coronavirus Disease 2019), Macular degeneration (a vision impairment resulting from deterioration of the central part of retina), Atrial fibrillation, Constipation, Arthritis, Osteoporosis, and Chronic Kidney Disease Stage 3 (moderate kidney damaged and notable loss of function, but they still work well enough without dialysis or a kidney transplant). Review of the quarterly MDS, dated [DATE], documented Resident #335 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. The initial kitchen tour was conducted on 07/31/23 at 8:51 AM, accompanied by the Executive Chef. During an observation in the walk-in cooler, it was noted that there was one full unopened case of unpasteurized shell eggs and a half of a case of unpasteurized shell eggs. It was also noted that there were no pasteurized shell eggs in the walk-in cooler. When the Executive Chef was asked how many staff cook eggs to order (e.g., over easy, sunny side up), the Executive Chef replied that the facility cooked eggs to order for the residents in the individual kitchens on the units without measuring the final cooking temperature of 145°F for 15 seconds for unpasteurized eggs. During a tour of the Biscayne Unit on 07/31/23 at 9:10 AM, it was noted that there were approximately 2.5 dozen unpasteurized shell eggs in the reach-in refrigerator, and no pasteurized shell eggs. During an interview with Staff A, Line Cook, when asked about cooking eggs to order, the Line [NAME] stated that she cooks eggs to residents' order for breakfast without measuring the final cooking temperature of 145°F for 15 seconds for pasteurized eggs. The line cook stated that none of the residents requested the eggs to be undercooked (e.g., sunny side up, over easy eggs) for breakfast on this day. When asked by the surveyor, Staff A was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized shell eggs. During a tour of the Key [NAME] Unit, on 07/31/23 at 9:55 AM, it was noted that there were no eggs in the reach-in refrigerator. During an interview with Staff B, Cook, when asked about cooking eggs to order for the residents, the [NAME] stated that he cooks eggs to order for breakfast, including breakfast that morning. The [NAME] stated that the eggs were removed from the reach-in cooler after it was identified by the surveyor that the eggs were not pasteurized. The [NAME] stated that he cooked an over easy egg without measuring the final cooking temperature of 145°F for 15 seconds for unpasteurized eggs for one resident on the unit, Resident #11, and that the rest of the residents had scrambled eggs made from pasteurized liquid eggs. When asked by the surveyor, Staff B was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview, on 07/31/23 at 12:04 PM, with Staff C, Dietary Aide on the Sweetwater Unit, when asked about residents ordering undercooked eggs, the Dietary Aide replied, none today, they only had three resident that asked for eggs. The Dietary Aide further stated the residents received scrambled eggs made from the pasteurized liquid eggs and that she cooks eggs to order when requested by residents. The staff were cooking the unpasteurized eggs without measuring the final cooking temperature of 145°F for 15 seconds. When asked by the surveyor, Staff C was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview with Resident #11, on 07/31/23 at 1:51 PM, when asked about the breakfast served this morning, Resident #11 replied, I had one over easy egg, with hash browns and a slice of bacon. Resident #11 further stated that he has one over easy egg several times a week. During an interview, on 07/31/23 at 5:22 PM, with a Sales Representative from [NAME] Wholesale 105593 Page 3 of 5 105593 08/03/2023 Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Fruit and Produce, the food vendor that the facility purchases their eggs from, the Sales Representative confirmed that the vendor did not have pasteurized shell eggs to sell and had never had them. During an interview, on 08/01/23 at 7:11 AM, with Staff D, Dietary Aide, when asked about residents that ask for and receive undercooked eggs, Staff D replied, 3 or 4 (residents). Staff D further stated that she prepared eggs to order based on residents' preferences. When asked, Staff D was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During the interview, on 08/01/23 at 7:37 AM, with the Registered Dietitian (RD), the RD stated that she was not aware that the facility was using undercooked, unpasteurized eggs, I assumed they were all pasteurized. During an interview, on 08/01/23 at 7:37 AM, with the Executive Chef and the Culinary Services Director, when asked about ordering and receiving shell eggs, the Executive Chef stated he had been ordering the unpasteurized shell eggs from [NAME] Wholesale Fruit and Produce vendor for the previous 5.5 months and that he had not ordered or received eggs from any other vendor. The Executive Chef stated that he ordered the eggs as he felt that the eggs that he was ordering were more natural and healthier. The Executive Chef stated that he was not aware that the eggs were unpasteurized. During a review of the website from Jack [NAME] Wholesale Fruit and Produce (where the facility buys eggs from) revealed that there were no pasteurized shell eggs that could be ordered from the supplier. During an interview, on 08/01/23 at 9:24 AM, with Staff E, Certified Nursing Assistant (CNA), when asked about residents being served undercooked eggs, Staff E stated that Resident #335 requests and receives over easy eggs once or twice a week. When asked Staff E stated that she was not aware of the risks of foodborne illness associated with residents' consuming undercooked unpasteurized shell eggs. During an interview, on 08/01/23 at 9:37 AM, with Resident #335, she confirmed that she ordered and received undercooked and unpasteurized shell eggs regularly. During an interview, on 08/01/23 at 1:12 PM, with Resident #334, when asked of her preferences for eggs, Resident #334 stated that she requested over easy eggs regularly for the 5.5 months that she had been in the facility. Resident #334 further stated that she has over easy eggs Monday, Wednesday and Friday, but I don't eat the yolks. Review of the invoices for the Jack [NAME] Wholesale Fruit and Produce vendor revealed the unpasteurized eggs were ordered on 02/03/23 and to be delivered on 02/03/23 to the facility. During an interview, on 08/01/23 at approximately 4:30 PM, the Administrator was told that the Agency had a concern related to the facility serving undercooked unpasteurized eggs. The Administrator stated she was not aware the facility was serving undercooked unpasteurized shell eggs prior to the concern being brought to her attention. During an interview, on 08/02/23 at 12:30 PM, with the Infection Preventionist, the Infection Preventionist stated that there had been no reports of residents with signs or symptoms of Salmonella illness. She confirmed she was not aware of the residents being served undercooked unpasteurized eggs. 105593 Page 4 of 5 105593 08/03/2023 Willowbrooke Court at Indian River Estates 2440 Citrus Blossom Cir Vero Beach, FL 32966

F 0812 During an interview, on 08/03/23 at approximately 9:00 AM, with the Medical Director by telephone, the Medical Director stated that he had been made aware of the concern by the Administrator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 105593 Page 5 of 5