Health inspection·April 28, 2025

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, record review, review of facility's policies and procedures, and staff interview, the facility failed to maintain a clean and sanitary environment in the kitchen and 2 of 2 nourishment rooms observed. The findings included: Review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces, last updated 8/19 indicated under 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g. daily, three times per week) and when these surfaces are visibly soiled. On 4/9/25 from 9:00 a.m., to 10:30 a.m., the following observations were made during a tour of the kitchen and nourishment rooms: On 4/9/25 at 9:10 a.m., and 10:21 a.m., a milky, brown liquid with solid particles was observed on the floor behind the ice machine in the kitchen. Photographic evidence obtained On 4/9/25 at 9:11 a.m., and 10:22 a.m., the floor under the dry storage shelf near the bathroom door in the kitchen was dirty with debris. Photographic evidence obtained On 4/9/25 at 9:12 a.m. and 10: 23 a.m., a green film was observed in the top corner of walk-in refrigerator in the kitchen. Photographic evidence obtained On 4/9/25 at 9:13 a.m., and 10:24 a.m., the pipes under the three compartment sink in the kitchen were dirty and actively leaking. A bucket with grey water was observed on the floor under the leaking pipes. Photographic evidence obtained On 4/9/25 at 9:15 a.m. and 10:25 a.m., food like debris and white film were observed on the fryer basket. Page 1 of 3 106070 106070 04/28/2025 Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266

F 0812 Photographic evidence obtained Level of Harm - Minimal harm or potential for actual harm On 4/9/25 at 9:16 a.m. and 10:25 a.m., a thick grease-like coating and dust-like substance was observed on the pipes and valves behind the stove. Residents Affected - Many Photographic evidence obtained On 4/9/25 at 9:20 a.m., coffee ground sized debris were observed on the counter behind the microwave in the nourishment room in patient care area. Dried food like residue was observed stuck to the baseboard and cabinet. Photographic evidence obtained On 4/9/25 at 9:25 a.m. and 9:40 a.m., black and green debris were observed under the sink in the memory care unit nourishment room. Photographic evidence obtained On 4/9/25 at 9:40 a.m., in an interview, the Maintenance Director stated, The housekeeping staff should be cleaning behind the microwave and on the cabinets if there is food debris. This is part of daily cleaning. The maintenance director was unable to identify the brown coffee ground sized debris behind the microwave. The Maintenance Director said the housekeeping staff should be cleaning under cabinets and could not say what the debris under the cabinets were. She said the staff does daily cleaning and should also be doing an assigned deep cleaning. Review of the cleaning record for the nourishment room of the Memory Care Unit revealed the most recent deep cleaning was done on 3/31/25. On 4/9/25 at 9:30 a.m., in an interview, the Maintenance Director said the leaking pipes under the three compartment sink were fixed before and she was not aware they were leaking again. She said staff should have put the leaking pipes in the TELS (electronic work order) system. On 4/9/25 at 9:42 a.m., in an interview the Director of Nursing (DON) was unable to identify the brown coffee ground sized debris behind the microwave of the nourishment room. The DON then brought some bleach wipes and stated, I need to clean this. On 4/9/25 at 10:21 a.m., in an interview the Dietary Manager stated, The kitchen staff will mop the whole kitchen at the end of their shift. She said she could see the debris under the shelving but did not know what it was. She again said it was the dietary department's job to clean it. She said they had to let go of the person who did the deep cleaning. She also verified there was green film in the walk in refrigerator and could not say what it was. She acknowledged the triple sink pipe was actively leaking but had not put in a work order to have it repaired. She said she has been employed at the facility since January and had identified concerns. She was slowly trying to get this place back together. 106070 Page 2 of 3 106070 04/28/2025 Desoto Health and Rehab 475 Nursing Home Dr Arcadia, FL 34266

F 0812 Level of Harm - Minimal harm or potential for actual harm On 4/9/25 at 11:13 a.m., in an interview with Housekeeping Staff A said, Part of my daily clean for a nourishment room, if I am assigned to them, is to wipe down sinks, remove the trash and wipe the outside of cabinets. The inside of the cabinet is part of the deep clean day. There is not a checklist for what exactly needs to be done in each area. Residents Affected - Many 106070 Page 3 of 3