Health inspection·December 3, 2020

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance related to lost items and reported to staff for one (Resident #70) of 30 sampled residents. The findings include: During an interview with Resident #70 on 11/30/2020 at 12:30 PM, she stated she had several dark clothing items that did not come back from laundry and that she really needed the items since it would be getting cold. She stated her name was written inside the items, but they were dark blue items so maybe her name was not seen. The three items were a navy pair of pants with a peach tribal design, a navy shirt with palm trees and a pair of navy flannel pants with stripes. She stated one of the staff members she told about the missing items was a certified nursing assistant (CNA), Employee C, who worked at night. She stated the items had been gone for at least a couple of weeks. A review of Resident #70's clinical record revealed she was admitted to the facility on [DATE]. A review of her admission minimum data set (MDS) assessment revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the grievance log for November 2020 found no grievances for Resident #7 and no grievances about missing clothing for the most recent three months. During an interview with Resident #70's nurse (Employee A) on 12/2/2020 at 8:24 AM, she was asked about the process for missing items. She stated for missing clothes, first they would get a description of the item. Then they would go to the laundry and look for it. If the item was not located, they would notify the Unit Manager or Social Services. Employee A was asked how long after not finding the item in the laundry she would wait to tell the Unit Manager or Social Services. She stated it would be the same day, within hours. She was asked if she was aware of whether Resident #70 was missing any items. She stated she was not. During an interview on 12/02/20 at 8:47 AM with the [NAME] Wing Unit Manager, she was asked if she was aware that Resident #70 had missing clothing. She stated she was not aware. During an interview on 12/02/2020 at 8:53 AM with Resident #70's CNA (Employee B) he stated he was not aware the resident was missing clothing. During an interview on 12/02/2020 at 9:39 AM with the Social Service Director (SSD), she stated she was informed on 12/2/2020 that Resident #70 had missing clothing. She stated she spoke with Page 1 of 4 105776 105776 12/03/2020 Port Orange Nursing and Rehab Center 5600 Victoria Gardens Blvd Port Orange, FL 32127

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #70 and reviewed her inventory sheet. The items the resident mentioned were not on it. She stated she checked the laundry and the items were not found. She stated they would probably be reimbursing the resident and she would speak with Employee C about reporting missing items. During further interview with the SSD on 12/02/20 11:44 AM, she stated she spoke with the CNA (Employee C) and the CNA informed her that Resident #70 told her she had missing clothing. The SSD stated the CNA told her that Resident #70 informed her three things were missing and all, but two came back from laundry. The SSD stated the CNA informed Resident #70 she would go to the laundry to look for the item and she did not. The SSD confirmed the CNA (Employee C) did not tell anyone about the missing items. . 105776 Page 2 of 4 105776 12/03/2020 Port Orange Nursing and Rehab Center 5600 Victoria Gardens Blvd Port Orange, FL 32127

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. Based on observation and interview, the facility failed to store and distribute food and beverages in a safe and sanitary manner to prevent foodborne illness, by failing to maintain a proper cold holding temperature of milk on the tray line to be supplied to residents and food held in a reach-in refrigerator. The facility also failed to maintain one (East Wing Nourishment Room) of three ice machines used for residents in a safe and sanitary manner. The findings include: 1. During an observation of the kitchen on 12/1/2020 at 11:30 AM, the cook was observed taking the temperatures on the tray line. During the tray line observation, the cook was asked to take the temperature of a small container of milk located in a grey plastic container in front of the tray line. The Assistant Food Service Manager took the half-pint carton of milk and used the facility thermometer to test the temperature of the milk. The temperature was 50 degrees Fahrenheit (F). She obtained a second half pint of milk from the plastic container and tested the milk at 45 degrees F. She obtained a third carton of milk and tested it at 47 degrees F. She was asked to check the calibration of the facility's digital thermometer. She put the thermometer in a cup of ice with a small amount of water and pulled the thermometer out when it reached 32.5 degrees. She retested the temperature of the three cartons of milk and they were at 50 degrees F, 45.2 degrees F and 46 degrees F. During an interview with the Assistant Food Service Manager on 12/1/2020 at 11:45 AM, she confirmed the findings. She stated they normally put the milk and juice in the plastic container and poured ice over it. She stated she did not know what happened today. During another observation of the kitchen on 12/3/2020 at 11:50 AM, the Assistant Food Service Manager was asked to take the temperature of a cold item in the reach-in refrigerator. She took out a package of sliced deli ham dated 12/3/2020, that was wrapped in clear plastic wrap in a plastic bag. She tested the temperature of the ham using a facility digital thermometer. The ham tested at 50.3 degrees F. The Assistant Food Service Manager was asked if the ham was heated prior to being placed in the refrigerator. She stated it was a package of deli ham that was taken out of the refrigerator and sliced for use for lunch today. She stated the ham placed back in the refrigerator was not heated. She stated it had been back in the refrigerator for 30-45 minutes. She did not know how long it was out of the refrigerator. She was asked to check the calibration of the thermometer. The Kitchen Manager was in the area and tested the thermometer in ice/water and it registered at 32 degrees. 2. During an observation of the East Wing nourishment room on 12/03/2020 at 9:17 AM, an observation was made of the inside of the ice machine. There was a black substance observed across the evaporator (white plastic bar) that ran across the back of the inside of the ice bin. There was water condensation dripping from the bar onto the ice. (Photographic evidence obtained) During an interview with the East Wing Unit Manager on 12/03/20 at 9:20 AM, she was asked who maintained the ice machine in the nourishment room. She stated the responsibility was shared between housekeeping and maintenance. She was asked to observe the inside of the ice machine. The East wing Unit Manager went into the nourishment room on 12/3/2020 at 9:21 AM and looked inside the ice machine. She confirmed the findings. A paper towel was then run across the white bar in the back of the ice machine and some of the black substance transferred to the paper towel. The Maintenance Manager joined the observation and stated he would clean the ice machine. 105776 Page 3 of 4 105776 12/03/2020 Port Orange Nursing and Rehab Center 5600 Victoria Gardens Blvd Port Orange, FL 32127

F 0812 . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 105776 Page 4 of 4