Inspection·March 13, 2024

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 observations, interviews, and record review the facility failed to ensure kitchen equipment was maintained in a clean manner for 1 of 1 ice machines located in the kitchen and related to ice/water dispensers located on 6 of 6 (Cabana Bay, Anchor Bay, Blueray Bay, Dolphin Bay, Emerald Bay, Florida Bay) living units. Findings included: An interview with the Dietary Manager (DM) on 3/13/24 at 8:59 AM revealed the main kitchen housed a large ice machine. She reported that there were ice/water dispensers in each of the 6 Chef Kitchens. A tour of the facilities kitchen and 6 Chef Kitchens revealed a large ice machine in the kitchen. Inspection of the ice machine revealed a white substance lining the inner left side of the ice machine walls. The ice machine had a wire rack located on the inside of the unit used to store the scoop. The scoop was noted to be lying sideways on the ice with the handle touching the ice. The Dietary Manager took the scoop off the ice and placed it on the rack. She did not notify any of the kitchen staff about the contaminated ice. She reported the scoop should have been on the rack when it was not in use. Tour of Chef Kitchens on each of the 6 living units revealed the following: -Cabana Bay-Ice/water dispenser noted with white and brown substance around the spout and white substance in the spill tray. -Anchor Bay-Ice/water machine with white and brown substance around the spout and white substance in the spill tray. - Blueray Bay-Ice/water machine with white substance around the spout and white and brown substance in the spill tray and settled water in the spill tray. -Dolphin Bay-Ice/water machine with brown and white substance around the spout and white substance in the spill tray. -Emerald Bay-Ice/water machine with white and brown substance around the spout. -Florida Bay-Ice/water machine with white and brown substance around the spout and white substance in the spill tray. (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: 106112 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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)