Health inspection·February 26, 2026

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, record review, and facility policy review, the facility failed to honor resident's food preferences by failing to provide an alternate food for 2 of 3 residents sampled for food choices. (Resident #12 and #159)The findings include:Resident # 12On 2/23/2026 at 1:56 PM, an interview was conducted with Resident #12. She stated she had allergy to red dye and because of that she did not receive tomato sauce when they were served spaghetti. She stated she had told the staff she would prefer some other kind of topping but she kept getting dry pasta without any sauce and she could not eat the pasta like that. On 2/25/2026 at 12:40 PM, the resident received her lunch tray inside the room. She was served spaghetti again without any kind of sauce. The meal ticket stated, Consistent carbohydrate diet, regular texture and thin liquids, allergy red No.40. There were no notes on dislikes or preferences on the meal ticket. (Photographic evidence was obtained)On 2/25/2026 at 1:22 PM the resident was on interviewed. She stated she did not eat lunch because they served spaghetti and she could not eat it. She further stated staff did not listen to her and she was not offered any alternatives. A record review of the resident was conducted. Resident #12 was admitted to facility on 8/28/25 with diagnoses including anxiety, schizophrenia, fibromyalgia, major depressive disorder schizoaffective bipolar type, and chronic pain syndrome. A dietary communication form dated 8/28/25 stated diet CCD (consistent carbohydrate diet), regular texture, allergy to red dye #40 and fortified foods with breakfasts. The most recent nutrition assessment was dated 2/3/26 and stated that the resident was receiving NAS (no added salt) diet. The assessment did not include any food restrictions due to red dye allergy.On 2/25/2026 at 1:33 PM, an interview was conducted with the Dietary Manager (DM). She stated Resident #12 had told her she did not want anything red on her food. She was asked if the meal ticket reflected her preferences and food dislikes. She stated the facility got a new system to print the meal tickets in October 2025, but they were having difficulty including the likes or dislikes on the meal tickets. She was asked if a resident had a red dye allergy that would lead to not being served tomato sauce. She stated that should not happen and that she would have to train the staff about it. She stated that if Resident #12 wanted tomato sauce, she will ensure she gets it. A review of tomato sauce that facility provided to resident was conducted, ingredients included tomato paste and citric acid as the ingredients, no red dye included. Resident #159On 2/25/2026 8:30 AM, Resident #159 was interviewed and stated she had issues with the lunch tray. She stated she was served a salad and she kept having to tell them she did not eat salads. The meal ticket had no menu items, preferences, or dislikes. The meal ticket stated, diet consistent carbohydrate, regular texture, thin liquids, double portions, likes: beverage of choice. She further stated she did not know what foods she was going to get for that day. A record review was conducted. Resident #159 was admitted on [DATE] with diagnosis including pseudonomas aeruginosa mallei, chronic kidney disease, heart failure, non-pressure ulcer heel and mid foot and Page 1 of 4 105662 105662 02/26/2026 Graceville Health Center 1083 Sanders Avenue Graceville, FL 32440

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few midfoot with necrosis of muscle, and type 2 diabetes mellitus with foot ulcers. Physician's orders include CCD (consistent carbohydrate diet), diet Regular texture, Regular/Thin consistency, NAS (no added salt), fortified foods with breakfast dated 1/30/26. A dietary communications form dated 1/30/26 has the diet as CCD regular texture, no added salt, regular liquids and fortified food with breakfast. A nutrition assessment dated [DATE] stated the resident was at risk of malnutrition related to obesity and increased needs or wound healing.On 2/26/2026 at 9:10 AM, a follow-up interview was conducted with the DM. She was asked how she was made aware of the resident's food likes and dislikes. She stated that, upon admission, she obtained a list. She further stated she would write it on a piece of paper and then would be entered in the computer so it will reflect in the meal ticket. She was asked how the residents know the menu for the day. She stated the menus were posted on all the halls. She further stated the Certified Nurse Assistants (CNAs) were supposed to tell the residents the menu of the day. If the residents did not want a specific food item on the menu, the CNAs will tell them the alternative, and the CNAs will fill out a form. She further stated when the CNAs bring in the tray, if the residents did not want something, they were supposed to replace it with one of the alternates. On 2/26/2026 at 9:23 AM, an interview was conducted with Staff A, CNA. She was assigned to work with both Resident #12 and Resident #159. She was asked to explain the process to communicate the daily menus to residents. She stated the menus were printed in the dining area, there were flyers there that they bring to the residents. She was asked if there was a specific time of the day that the flyers were distributed and filled up. She stated she was unsure and she did not have the chance to do it today yet.On 2/26/2026 at 9:31 AM, an interview was conducted with Staff B, CNA. She stated the facility protocol was to read the printed menu located at main dining area and go room to room and verbally tell the residents what they were going to have for lunch for the day. If the resident did not want something from the menu, they were able to get an alternate. Staff will bring an alternate menu form and fill out the form. She stated forms were supposed to be done before 9:30 AM every day. She stated she had not gotten around to it yet. The facility policy Food Preferences (dated [DATE]) states, A written record shall be maintained of the resident's likes and dislikes. This will also include diet order, which indicates any dietary restrictions. The food likes and dislikes of each resident are determined through a dietary food preference sheet. It will be noted in the record when a food preference have been updated, changed or reviewed. 105662 Page 2 of 4 105662 02/26/2026 Graceville Health Center 1083 Sanders Avenue Graceville, FL 32440

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to maintain a complete medical record for 1 of 3 residents sampled for wound care. (Resident #159)The findings include:On 2/24/2026 at 2:24 PM, an interview was conducted with Resident #159. She stated wound care was scheduled daily but the facility was not providing wound care on the weekends.A review of Resident #159's medical record was conducted. The resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with foot ulcers. Physician's orders included Acetic Acid irrigation solution 0.25% apply to bilateral heels topically every day shift related to foot ulcer, apply acetic acid moistened gauze to wound bed, and cover with BD (a basic sterile gauze dressing) pad and wrap with kerlix and secure with tape daily and as needed. A review of the February 2026 Treatment Administration Record (TAR) revealed no documentation of wound care on Saturday, February 7th and Friday, February 20th.On 2/25/2026 at 2:25 PM, an interview was conducted with the Director of Nursing (DON). She reviewed Resident #159's the missing wound care documentation on February 7th and February 20th. She stated she was going to look into it because sometimes Resident #159 would go out of the facility for the day with a family member. She clarified that expectation was to have documentation completed and if refused or treatment was not performed, to document the reason. On 2/25/2026 at 3:38 PM, a follow-up interview was conducted with DON. She stated she spoke with the staff that performed wound care on the 7th and stated she did the wound care that day but did not document it but she documented it as a late entry today. The DON further stated that the wound care orders changed on the 20th, so the old order was discontinued and the new order placed later so the nurse had no way to see the order because the order was discontinued when it was performed. The DON stated the staff member was going to write a late entry progress note to reflect the wound care was done on the 20th. 105662 Page 3 of 4 105662 02/26/2026 Graceville Health Center 1083 Sanders Avenue Graceville, FL 32440

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to maintain all mechanical, electrical, equipment in good operating condition during 2 of 2 observations of the kitchen. The findings include:On 02/23/2026 at 11:17 AM, an observation of the kitchen revealed several areas of disrepair. There were multiple doorjambs, windowsills, and walls in need of repair. The sheet metal covering the outside of the walk in cooler entrance was rusted and deteriorating at the base where the walls meet the floor. On 02/25/2026 at 1:37 PM a second observation of the kitchen revealed the same several areas of disrepair. Upon entering the kitchen, there is a steam table that is wrapped around the lower section of the outside with a plastic skirting that appears to be falling apart at the bottom with several pieces broken off. Observation of the door entering the room where the dishwasher is located is rusted around the doorjamb and the wall adjacent to the door is covered over with the same plastic skirting used under the steam table. The wall is separating from the structure and is bowing out exposing the inner structure behind the walls. Additionally, there is only one functioning overhead light in this room, with two others not functioning. The second door leading from the dishwasher room has the same plastic covering adjacent to the door that is bowing out and cold air is blowing from the gap. The Dietary Manager (CDM) confirmed at this time that this air is coming from the walk in freezer and cooler that sits behind the wall. There is a windowsill just over the first sink of the 3 compartment sink that contains rust that is flaking off. The Registered Dietician (RD) confirmed the need for repair and had covered over the flaking rust with duct tape. The metal walls around the walk in cooler/freezer are rusting where the wall meets the floor. There are doorjambs in the dry storage closet that are rusted and completely disintegrated. These observations were shown to the RD, CDM and Regional Nurse Consultant, who all confirmed this these areas are in need of repair/replacement. (Photographic evidence obtained) Residents Affected - Few 105662 Page 4 of 4