Health inspection·February 18, 2021

F 0761 - Triamcinolone acetonide 0.5% topical ointment (1 application) Ointment (gram) topical as needed three times daily starting 3/18/2019 Level of Harm - Minimal harm or potential for actual harm - Triamcinolone acetonide 0.1% topical cream (1) cream (gram) topical everyone day starting 3/1/2020 Residents Affected - Few The current active physician orders for 2/2021 did not include: - 1.59 oz tube of Betamethasone Dipropionate Cream. - 30 g tube of Nystatin Cream. A review of the facility policy titled, Medication Storage (Medication Cart/Narcotics), last review date of 1/2021 revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure temperature and security. The policy continued to indicate the Policy Explanation and Compliance Guidelines as: 1. General Guidelines: A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . C. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 2 of 4 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility did not ensure food equipment was stored and handled in a sanitary manner related to cleaning and sanitization of food contact equipment and serving utensils. Findings included: During the comprehensive kitchen tour on 02/17/21 at 10:28 a.m. with the Certified Dietary Manager (CDM), Staff C, Chief was observed in the process of cleaning the deli slicer. Staff C, Chief began disassembling the slicer and stated the facility procedure is to clean and sanitize the slicer after each use. Staff C stated the deli blade and stand are cleaned and sanitized on the countertop area. Staff C used a dry cloth to remove large food debris from the blade and stand before retrieving a butter knife to assist with scrapping off additional food debris from the front and back portion of the equipment blade. Staff C sprayed [Brand Name] sanitizer onto the deli slicer and immediately wiped the sanitizer from the equipment. Staff C, Chief walked away from the deli slicer and the CDM confirmed the cleaning and sanitization of the equipment was completed. Staff C, Chief did not use soap, water, or re-spray the [Brand Name] sanitizing spray after immediately wiping off the sanitizer during the cleaning process. Upon examination of the deli slicer post-cleaning and sanitizing, old food debris chunks were still present on the back-blade portion at the top section. The CDM confirmed the food debris on the deli slicer post-cleaning and confirmed the equipment would be considered a food contact surface. The CDM confirmed she was aware of the foodborne illnesses that are associated with deli meats and improper cleaning of food-contact surfaces. During an observation on 02/17/21 at 10:37 a.m., a stand mixer was stored underneath a plastic covering. The CDM confirmed the stand mixer was considered clean. The CDM removed the plastic covering and upon examination of the mixing stand, old food debris was observed on the underside of the stand mixer above the mixing bowl. The CDM confirmed the food debris presence and instructed Staff C, Chief to re-clean the equipment. During an observation on 02/17/21 at 11:28 a.m., facility kitchen staff were observed preparing the food service line for lunch. Staff D, [NAME] was wearing gloves, leaned against the stove top with hands placed directly on the stove area. Behind Staff D, two ladles were placed directly onto the counter area. Staff D, without changing his gloves, began removing bowls from the storage rack, flipping them over, and touching the inside of the bowl with his fingers before placing the bowls onto the food service line. Staff C asked Staff D if he had ladles to serve the soup with. Staff D, [NAME] proceeded to grab the ladles from the countertop to show Staff C and placed them down onto the bowl storage rack without a clean barrier. Staff C placed the ladles into the food items on the steam table without re-cleaning the equipment. During an observation on 02/17/21 at 11:30 a.m., Staff B, [NAME] walked away from the food service line to a wire rack. Staff B returned from the wire rack carrying approximately six food serving scoops. Staff B held the serving scoops in his hands by his waist. As Staff B walked back to the food service line, the scoops continually brushed against his pants and shirt. Staff B walked past Staff C, Chief resulting in the scoops held in the left hand to brush against the clothing of Staff C, Chief. Staff B placed the scoops directly into the food stored on the steam table, without cleaning or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 3 of 4 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 105694 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sabal Palms Health & Rehabilitation 499 Alternate Keene Rd NE Largo, FL 33771 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 sanitizing the food equipment. Staff B began scooping and preparing resident food trays. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/17/21 at 11:40 a.m. The CDM and Staff C, Chief confirmed that once the food serving equipment touched another surface, it should be re-sanitized prior to being placed inside of the food. Residents Affected - Few A review of the manufacturer instructions for use of the [Brand Name] sanitizing spray revealed, Sanitizing Food Contact Surface Directions . Prior to application, review, gross food particles and soil by pre-wash, pre-scrape, or pre-flus, and when necessary pre-soak. Thoroughly wash or flush equipment with a good detergent or compatible cleaner followed by a potable water rinse before applying sanitizer. Apply [Brand Name] Sanitizer to pre-cleaned hard non-porous surfaces with cloth, mop sponge, or sprayer or by immersion. Surfaces must remain wet for 60 seconds (one minute) Allow to air dry before reuse. A policy review of Sanitation of Dining and Food Service Areas, dated January 2021, revealed, Culinary services staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule . Employees will be trained on how to perform cleaning tasks and any protective equipment that is required to be worn during these tasks as appropriate. According to the Food and Drug Administration (FDA) Food Code 2017, page 148, revealed, . Equipment food-contact surfaces and utensils shall be sanitized . Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning . Page 504-505, under Section: Equipment revealed, . a chemical sanitizer will not sanitizer a dirty dish As a result, pathogenic microorganisms may be transferred to foods that are prepared on such surfaces Equipment or utensils may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105694 If continuation sheet Page 4 of 4