Health inspection·May 13, 2021

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that she may be having a heart attack. She explained that a full set of vitals would be taken and the physician would be contacted. She went on to say, Because I know her, I feel like it is more of an anxiety issue. On 5/11/21 at 12:50 PM an interview was conducted with the resident. She confirmed that she had suffered a heart attack in the past and that the arm/shoulder pain she was experiencing felt just like this. The resident requested to be evaluated by a doctor. Regarding the symptom of being fuzzy, the resident explained that her vision was blurry and that she was extremely fatigued. She confirmed that these symptoms were new onset. The resident's request to be evaluated by a doctor was relayed to the resident's assigned nurse on 05/11/21 at 12:56 PM. On 05/11/21 at 12:56 PM an interview was conducted with Employee N, RN. She explained that she had notified the physician of the resident's concerns and that a chest x-ray, labs, and an electrocardiogram (ECG) were ordered. The nurse was asked whether the ECG had been ordered to be done as soon as possible. She replied that it would be done sometime today. On 05/11/21 at 03:16 PM, approximately approximately four and a half hours after the resident's initial complaint, the radiology technician arrived to the facility to perform the x-ray and ECG. On 05/12/21 at 01:12 PM an interview was conducted with the Director of Nursing (DON). She explained that for a resident who presented with signs and symptoms of a heart attack, the facility would notify 911. She went on to explain that because the facility knows the resident's behaviors and anxiety, 911 was not called. The DON was asked for the facility's policy regarding changes in condition and emergency response. She stated she didn't believe the facility had a policy for either topic. A policy was not produced during the survey. On 5/12/21 the results of the ECG indicated consider anteroseptal myocardial damage. (Photographic Evidence Obtained) On 05/13/21 at 11:23 AM an interview was conducted with the resident's attending physician. He explained that his expectation was that an EKG should be done now. He stated, there is no such thing as a routine EKG. According to Merck Manual https://www.merckmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/chest-pain (accessed 5/11/2021): A high index of suspicion is important when evaluating patients with chest pain. For adults with acute chest pain, immediate life threats must be ruled out. Most patients should initially have pulse oximetry, electrocardiogram (ECG), and a chest x-ray. Evaluation must be prompt so that patients with ST-elevation myocardial infarction or other criteria for intervention can be in the heart catheterization laboratory (or have thrombolysis) within the 90-minute standard. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 2 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, and resident record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one out of 26 residents. (Resident #36) Residents Affected - Few The findings include: On May 11, 2021 at 9:29 AM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup lid was dated Sunday, 5/9/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) Resident #36 was observed lying in bed with head of bed elevated, pleasant and conversant. She was asked if she used the straw that was in her cup to drink her water. She stated, Yes, I suppose so. On May 12, 2021 at 12:15 PM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup lid was dated Tuesday, 5/11/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) On May 13, 2021 at 9:05 AM a plastic cup was observed to be filled with water on Resident #36's tray table. The label on the cup was dated Wednesday, 5/12/2021. A straw was noted in the cup, and the label stated Resident #36's name and no straws. (Photographic evidence obtained) On May 13, 2021 at 09:07 AM an interview was held with floor nurse, Employee C. She confirmed that she was caring for Resident #36 today. She did not know why Resident #36 has had a straw in her bedside water cup. When asked if she was aware the label on her water cup says no straws she stated, No, I'm not sure. When asked if Resident #36 is not supposed to use straws she said, No, I'm not sure. I'll have to ask the unit manager. On May 13, 2021 at 10:26 AM an interview was conducted with Employee B, Unit Manager. She confirmed Resident #36 had an order for no straws. Regarding the reason, Employee B replied, She has a history of aspiration. The speech therapist had seen her and determined she should not use straws. I just went around and did an in-service with all staff about following the orders for not using straws. On May 13, 2021 at 1:09 PM an interview was conducted with Employee A, Speech Therapist. Regarding Resident #36's status of no straws and the reason she stated, Typically an order for no straws is due to decreased lingual strength and the ability to control the liquid bolus, but the desire to continue on thin liquids. Resident #36 is at an aspiration risk, and for her, using a straw puts her at a higher risk for aspiration. A review of the current orders for Resident #36 revealed a diet order written on October 14, 2020 which read, NAS (no added salt) Special instructions: No straw. Side of gravy with meat. Upright for all intake. May require assistance with cutting food items into small bite size pieces. A review of Resident #36's care plan, dated April 4, 2020 and revised March 30, 2021 revealed the following focus, goal and interventions: Focus: Resident is at nutrition and/or hydration risk as evidenced b: consumes less than 75% of food and/or fluids at most meals, dementia, low pre-albumin, requires oral supplements to meet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 3 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm nutritional needs, ride sided weakness, at risk for skin breakdown, requires assist with meat cut up into bite size portions and gravy on the side to increase mastication. Goal: Resident will remain adequately hydrated as evidenced by good skin turgor, pink and moist membranes, and sufficient fluid intake through next 30 days. Residents Affected - Few Interventions: Monitor for skin breakdown. No straws for drinking. Nursing to cut up meat when needed. Provide house shakes at/between meals. May have fluctuating mental status, monitor at meal times and provide supervision/assistance as needed. Observe for s/s dehydration and report to nurse. A review of the Speech Therapy Progress and Discharge Summary for Resident #36, dated Start of Care 10/08/2020 and End of Care 10/14/2020 revealed precautions which specify aspiration precautions, regular/thin liquids, no straw. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 4 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to adequately monitor for the use of antipsychotic medications for 1 of 7 residents reviewed for unnecessary medications from 26 sampled residents. (Resident #9) Residents Affected - Few The findings include: Record review revealed Resident #9 was a [AGE] year old female admitted on [DATE] with a diagnosis of vascular dementia and major depression. The review of the Quarterly Review of the Minimum Data Set (MDS) completed 4/22/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, and a Mood Severity score of 07 indicating some depression. The medication orders included Abilify 5 mg daily for depression, Bupropion HCI 300 mg daily for depression, Doxepin 3 mg daily for depression, and Vilbryd 40 mg daily for depression. The medical record did not reveal any orders for the monitoring of behaviors for the ordered medications. Review of the care plan revealed a focus area for the use of medications with a potential risk for adverse consequences related to antipsychotic medications. Interventions included to assess effectiveness of drug treatment, attempt GDR (gradual dose reduction) if not contraindicated, and monitor resident's behavior and response to medication. Review of the April and May 2021 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) did not reveal any monitoring of behaviors for the administration of the antidepressant and antipsychotic medications. On 5/12/21 at 1:36 PM an interview was conducted with the Director of Nursing (DON) who was asked if behavioral monitoring is conducted on residents receiving antipsychotic or antidepressant medications. The DON stated an order is put into the Electronic Medical Record (EMR), and the nurses document on the MAR/TAR their observations. The DON was asked if there was an order for Resident #9 to have behavior monitoring. The DON reviewed the EMR and confirmed there was no order; therefore it did not appear on the MAR/TAR for the nurses to document their observations. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 5 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviews and observations, the facility failed to ensure medication error rates were below five percent by failing to administer eye drops appropriately for one of eight (Resident #171) residents reviewed during observations of medication administration. The medication error rate was 6.25% with 2 errors out of a total of 32 opportunities for errors. Residents Affected - Few The findings include: A review of the medical record for Resident #171 was conducted. She was admitted to the facility on [DATE]. Her primary medical diagnosis was fracture of the left femur. The resident's cognition was intact and she required extensive assistance with activities of daily living. A review of the care plans for Resident #171 revealed a focus area for visual disturbances which indicated the resident required the use of prednisolone eye drops. A review of the resident's physician orders revealed an order dated 5/6/21 which read, prednisolone acetate drops suspension 1%, one drop in both eyes three times daily. On 5/12/21 at 4:26 PM an observation of medication administration for Resident #171 was conducted with Employee N, Registered Nurse (RN). She instilled one drop of the prednisolone ophthalmic solution to the resident's left eye. She then instilled one drop of the prednisolone ophthalmic solution to the resident's right eye. The nurse failed to apply pressure to either eye after administering the medication. The nurse also failed to instruct the patient to keep her eyes closed for 1-2 minutes to allow absorption of the medication into the eyes. A review of the facility's medication administration policy titled Medication Administration: Eye Drops was conducted. The policy was last revised on 1/30/20. The policy directed staff to instruct the patient/resident to close eyes slowly to allow proper distribution of drops over surface of the eye and to keep eyes closed for 1-2 minutes. According to Mayo Clinic, https://www.mayoclinic.org/drugs-supplements/prednisolone-ophthalmic-route/proper-use/drg-20406320 (accessed on 5/13/21), keep the eye closed and apply pressure to the inner corner of the eye with a finger for 1 or 2 minutes to allow the medicine to be absorbed by the eye. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 6 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

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, staff interview and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness for all but one of the residents in the facility. The dietary staff failed to follow the proper procedures for hand hygiene, disposable glove use, food storage, date marking and proper sanitation practices in the kitchen. Specific instruction and procedures on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: Observations made during the initial tour of the kitchen on 05/10/2021 at 11:10 AM, with Employee D, Dietary Manager, included the following: Debris from the cardboard boxes and containers was observed on floor of the walk-in freezer. The floors under and behind the ice machine, the food warming ovens and the deep fryers were observed to have a build-up of food debris and grime. The food warmer oven had crumbs of food debris on the ledge under the controls and caked on food that had run out under the top oven door. There was a build-up of stuck on grease between the two fryers. The stand mixer had encrusted food on the under carriage and the inside of the stand. The air vents throughout the kitchen had a black biological growth on them. A drain under the main prep table was covered with built up black grime. There was stuck on food and grime in the grout of the floor throughout the kitchen. A food scoop was observed on the rack with the clean utensils with dried on food stuck to it. (Photographic evidence obtained) In the walk-in cooler two plastic storage bags containing partially used deli meat were observed. One bag was date marked 04-27 with a black marker. One bag was marked Open 5-2 with a black marker. Another partially used bag of deli meat was observed with no date mark and the bag was not sealed. (Photographic evidence obtained) During a second tour of the kitchen on 05/12/2021 at 11:30 AM, Employee H was observed preparing chef salads. She had taken the bag of sliced deli meat with the date mark of 5-2, opened it, cut the meat into slices, and placed it on top of the prepared salads. During an interview on 05/12/2021 at 11:43 AM, Employee D was asked about the date marking of the deli meats that were observed on 05/10/2021 during the initial tour. Review of the date marking guide indicated that deli meat should be discarded 5 days after opening the original package if not used. He was informed of the deli meat, marked 5-2, being used by Employee H to make the chef salads. He immediately went to the prep table and looked at the date mark on the bag of the deli meat. He instructed Employee H to throw the salads and deli meat away, and to make new salads with fresh deli meat. Employee H stated she thought she was using a new package she had opened more recently. During the lunch meal observation in the kitchen on 05/12/2021 at 11:50 AM, Employee G, removed the pans of prepared food from the warmers, removed the plastic wrap covering them and placed them in the steam table. He dropped a crumpled wad of plastic wrap on the floor in front of the steam table and walked away. Employee F walked over, picked up the plastic wrap with her gloved hands and threw it in the garbage can under the handwashing sink near the tray line. She did not change her gloves and wash her hands. She proceeded to set up the trays, plate the food and place a dinner roll on each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 7 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm plate without changing her gloves and washing her hands. At 12:20 PM, Employee F was observed moving the food with her gloved hands to the place on the plate where she wanted the food. She did this on several plates and did not change gloves. She used a dry towel to wipe the gloves and continued to plate the food, touching various surfaces with the contaminated gloves. She plated 76 residents' food without changing her gloves or washing her hands. Residents Affected - Many During an interview with the Employee D on 05/12/2021 at 1:42 PM, he stated that Employee H told him that she did not check the date on the deli meat, and she should have. He stated the dietary staff have been trained and they know to check the date mark on items in the cooler prior to using them. During an interview with Employee E, Certified Dietary Manager, on 05/13/2021 at 1:45 PM, she stated that the kitchen has not been deep cleaned for some time. The facility is having trouble filling all the dietary positions and because of that the deep cleaning has not been done. She stated, We know it needs to be done. She produced a cleaning schedule for the kitchen that was blank and stated, It isn't being done. (Copy obtained). Review of the facility policy and procedure entitled Bare Hand Contact with Food and Use of Plastic Gloves, effective 10/01/2017 and revised 10/18/2017, revealed it read: It is the policy of [Facility] plastic gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handler's hands to the food product being served. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose and discarded when damaged or soiled. Hands are to be washed before putting on the plastic gloves. Anytime a contaminated surface is touched the gloves must be changed including but not limited to the following: After handling garbage or garbage cans, after handling anything soiled, after picking up an item off of the floor, anytime you touch a contaminated surface. Wash hands when removing and/or changing gloves (Copy obtained). Review of the facility policy and procedure entitled Labeling, Dating and Storage, effective 06/01/2016 and revised 10/18/2017, revealed it read: It is the policy of [Facility] for all partners who assist in handling, preparing, serving and storing food items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. 1. Food items will be properly labeled with the name of the item and a use by date. 2. Food will be stored in their original container or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. 3. Prepared food items will be discarded according to the USDA Quick Reference Shelf Life List. 4. Those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with a use by date based on the USDA Quick Reference Shelf Life List (Copy obtained). Review of the facility policy and procedure entitled Receipt and Storage of Food & Supplies, effective 09/01/2001 and revised on 03/24/2016, revealed it read: 4. All storage areas will be clean, organized and ready to receive deliveries. 8. Floors must be swept and mopped daily (Copy obtained). Review of the facility policy and procedure entitled Quick Reference Shelf Life List, effective 11/22/2017 and revised on 02/23/2018, revealed it read: All opened refrigerator items must have a use by date. All items will be dated on date of arrival. Deli Meats: 5 days (Copy obtained). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 8 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on kitchen food service observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to ensure that all mechanical equipment in the kitchen was maintained in a safe operating condition. The facility failed to ensure that the dietary staff were trained and knowledgeable about the proper procedures for the safe operation of the dish machine. Failing to sanitize the dishes may potentially lead to negative health outcomes for the residents. Residents Affected - Many The findings include: During the initial tour of the kitchen on 05/10/2021 at 11:10 AM, Employee H was observed operating the dish machine. The machine was run through 5 cycles and the wash cycle temperature only reached 156' F to 158'F, and the rinse cycle only reached 178'F. Observation of the machine specifications posted on the side of the machine revealed it read: Wash cycle minimum temperature: 160'F. Rinse cycle minimum temperature: 180'F. (Photographic evidence obtained) Employee H stated the machine was a high temperature sanitization machine. She confirmed the water temperature was not high enough to sanitize the dishes, stating it needed to be minimally 160'F for the wash cycle and 180'F for the rinse cycle. A large plastic bucket of chlorine sanitizer was observed under the machine with a clear plastic hose running out through the lid of the bucket into the machine. During an interview on 05/10/2021 at 11:25 AM with Employee H she was asked about the use of small canister of chlorine test strips on top of the machine. When asked if she uses the chlorine test strips to test the sanitizer level, she stated yes. She took a chlorine test strip and tested the water when the machine finished another cycle. The test strip registered 0 parts per million (ppm). She then took a quaternary (quat) ammonium test strip from a shelf above the ware washing sinks on the other side of the dish room. She ran the machine again. The quat test strip registered 0 ppm. When asked to explain why she was testing for chemical sanitizer if it was a high temp machine, she stated that if the machine does not reach a high enough temperature, then the chemical sanitizer works. She was not able to explain how the machine worked. She did not know what type of chemical was used in the machine. She pointed to the dispenser on the wall and said, It's whatever they fill that with. The water temperatures for the wash cycle were still only reaching 158'F and the rinse cycle only 178'F. Employee H stated the chemical sanitizer should be automatically working since the temperatures are not high enough. During an interview with the Certified Dietary Manager (CDM) on 05/10/2021 at 11:30 AM, she was not certain how the machine switches from high temperature to chemical sanitation. She thought the chemical used in the dish machine is chlorine. She tested the sanitation with the chlorine test strips and the test strip registered 0 ppm. She could feel the chemical on her hands and was sure it was dispensing the chemical sanitizer during the rinse cycle. During an interview with the Dietary Manager (DM) on 05/10/2021 at 11:33 AM, he stated that the dish machine is a hybrid. It uses high temperature sanitation and chemical sanitation. He was not able to explain how the machine works. He knew that if the temperature did not rise to a high enough level, the chemical sanitizer is supposed to kick in. When informed about the test strips registering 0 ppm, he was not sure how the machine is set up to switch from high temp to chemical sanitation. He was informed that the temperature of the water was not high enough in the wash or rinse cycle. He ran the machine and observed the temperatures to be: Wash cycle = 158'F and the Rinse cycle = 178'F. He stated that sometimes it does not get to the right temperature and he has to call the contracted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 9 of 10 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 106124 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth - Fleming Island 2040 Town Center Blvd Fleming Island, FL 32003 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)

F 0908 Level of Harm - Minimal harm or potential for actual harm maintenance provider to come work on the machine. He thought the chemical sanitizer for the machine in the bucket was chlorine and since the machine was not reaching a high enough temperature, the chemical sanitizer should be working. He could not explain why the test strips registered 0 ppm. He was not able to determine when the machine had last been functioning properly. He stated he would use paper plates for the lunch meal service and rewash all of the dishes when the machine was fixed. Residents Affected - Many During an interview on 05/10/2021 at 1:20 PM with the representative from the contracted maintenance provider for the dish machine, who was on site working on the dish machine, he confirmed that the water temperatures were not hot enough. He explained that he had to adjust the water heater booster and make some other adjustments to the machine. He explained the machine is a hybrid machine. When the water temperature does not reach 160'F during the wash cycle and 180'F during the rinse cycle, minimally, the machine is to be switched manually by the dietary staff member running the machine to chemical sanitation. He pointed to a control box on the wall above the dish machine and explained how the electrical wiring is to be plugged into a receptacle inside the box and then the chlorine in the bucket under the machine will start to dispense into the machine. He confirmed that the machine must be switched manually. It does not automatically change from high temp to chemical sanitization. The staff have to watch the temperature gauges to determine if and when the machine needs to be switched from high temp sanitation to chemical sanitation. Review of the facility policy and procedure entitled Dish Machine Rinse Additive Use revealed it read: When the temperature on the wash cycle goes below 160'F or the sanitizing cycle goes below 180'F, 3. Turn on the sanitizer manually (show the staff where and how). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106124 If continuation sheet Page 10 of 10