Inspection·April 17, 2024

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 review of facility policy, the facility failed to adequately clean fixed equipment (oven, fryer, and other surfaces) and ensure these surfaces were free from buildup and contamination via splashes, dust, and grease. This has the potential to affect 52 of the 56 residents who were consuming food prepared in the facility's kitchen. The findings include: On 4/15/24 at approximately 10:30 AM, during the initial kitchen tour, observations were made of a heavy thick build of multiple layers of various texture and color substances, splashes, and build up adhered to the front and sides of the stove, fryer, oven, and other fixed equipment surfaces. There was a dark color buildup, a layer of yellow splattered sticky substances, and layers of a dusty white substance on the front sides and inside doors of the oven and stove. The same layers were observed on the fryer, and surfaces of other fixed equipment in the kitchen. The Director of Dining Services (CDM) explained that the buildup was oven cleaner that had not yet been wiped off. He showed the surveyors a used stove that the facility had purchased but not yet installed. The manager explained that staff had been focusing on cleaning the used stove to get it ready for installation soon. (photographic evidence obtained) On 4/17/24 at approximately 12:50 PM, a second tour of the kitchen was conducted with Dining Services Technician B. Some of the white substances had been removed from surfaces but multiple thick layers of buildup were still on fixed surfaces of the fryer, oven, and stove. The surveyor inquired about surface cleaning procedures for fixed equipment such as stove and fryer. Dining Services Technician B explained that they were getting new equipment and they have not had time to really clean the surfaces of the stove and oven that was currently in use for quite a while. (photographic evidence obtained) A review of the employee cleaning list for 4/15/24, 4/16/24 and 4 /17/24 was conducted. Line #6 on the check off sheet listed that the cook is responsible for cleaning oven top, racks inside the oven door, oven racks, back of inside of the door and outside surfaces. These tasks were initialed as having been completed on 4/15/24 and 4/16/24. A review of the job description for Dining Services Technician was conducted. The job description directed Dining Services Technicians to maintain a clean, hazard free work area and ensure that the department is maintained in a clean and safe manner by assuring that necessary equipment and supplies are maintained. A review of the job description for director of dining services was conducted. The job description (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 2 Event ID: 105729 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 105729 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chipola Health and Rehabilitation Center 4294 3rd Avenue Marianna, FL 32446 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)