Inspection·April 23, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 failed to ensure food items were stored in a safe and sanitary manner in bistro of the facility. Residents Affected - Few Findings include: During an observation on 4/23/2024 at 9:13 AM, while conducting a tour of the facility's bistro with the Certified Dietary Manager, there were four undated and unlabeled individual containers of pureed fruit stored in the cabinet, one of which was opened; one uncovered sherbet cup of granulated sugar stored on top of the counter; one container of whipped topping with an open date of 3/3/2024 stored in the cabinet; spillage on the bottom edge of Cooler #1; one undated and unlabeled cut lemon wrapped in plastic wrap stored in Cooler #2; two top cabinet drawers containing speckled black and brown debris; one gallon of dill pickles stored in the sink, with the top of the pickle jar with inscribed warning to refrigerate after opening; no thermometer in the ice cream storage bin; and black and brown speckled debris in the ice cream scoop bin. During an interview on 4/23/2024 at 9:13 AM, the Certified Dietary Manager confirmed the opened, undated, and unlabeled food items stored in the bistro. The Certified Dietary Manager stated the bistro area needed cleaning and that there needed to be a thermometer in the ice cream storage bin. During an interview on 4/23/2024 at 11:50 AM, the Activities Director stated, I know the residents and their families really enjoy the food [in the bistro]. Review of the facility policy and procedure titled Sanitation/Infection Control reviewed on 9/28/2023, showed the policy read, Effective sanitary practices include, but are not limited to, the following: a. The Dietary Manager is responsible for supervising all sanitation and housekeeping procedures within the Dietary Department . c. The Dietary Manager is responsible for supervising and training all personnel in proper sanitation procedures for storing, preparing, and serving foods. 2. i. Leftover foods are placed in shallow containers, dated, labeled, and chilled rapidly. These foods are used within 48 hours. Review of the facility policy and procedure titled Cleaning and Sanitizing Dietary Areas and Equipment, reviewed on 9/28/2023, showed the policy read, All kitchen areas and equipment shall be maintained in a sanitary manner and be free of food, grease or other soil. The facility will provide sanitary food service that meets state and federal regulations. Review of the facility policy and procedure titled Food Storage reviewed on 9/28/2023 showed the policy read, 15. Leftover food is stored in covered containers or wrapped carefully and securely. Each (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: 106095 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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)