Inspection·January 20, 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 kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to date mark numerous open food packages in the dry storage room, the refrigerator, and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 1/17/2023 at 8:20 a.m. During the tour, no date markings were observed on a bin filled with fresh vegetables, an open box filled with pineapples and melons, another open box filled with asparagus, or an open bag of brussels sprouts and carrots on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of blueberries sitting on a shelf in the walk-in freezer. In the dry storage room, there was no date marking observed on one open bag of corn starch. On the opposite side in the dry storage room, on the bottom shelf, there were no date markings identified on four open pasta bags. The bread rack next to tray line had three open bundles of bread with no date markings. These observations were made again on 1/17/2023 at 12:47 p.m., 12:48 p.m., and 12:49 p.m. During the same time, new observations of a bin filled with carrots, one package of cauliflower and five lemons placed on top of a box, and an open box of tomatoes were on the shelf in the walk-in refrigerator with no date marking. (Photographic evidence obtained) A follow-up tour of the kitchen was conducted on 01/19/23 at 10:45 a.m. In the dry storage room, there was no date marking observed on one open bag of corn starch. On the opposite side in the dry storage room, on the bottom shelf, there were no date markings identified on four open pasta bags. The bread rack next to the tray line had two open bundles of bread with no date markings. No date markings were observed on the open bag of celery, vegetable bin filled with vegetables, open box of asparagus, open box of melons, or one package of cauliflower and five lemons placed on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of blueberries or one open bag of biscuits sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) An interview was conducted on 01/20/23 10:17 a.m. with Dietary Aide (DA) A, who confirmed that the facility policy for date marking was to ensure open food was covered, labeled, and dated, and that leftover bread was wrapped, date marked, and discarded after three days. An interview was conducted on 01/20/23 at 10:38 a.m. with [NAME] B, who stated he and the Director (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: 105820 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 105820 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE University Crossing 6210 Beach Blvd Jacksonville, FL 32216 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)