Inspection·February 5, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 02/04/21 at 12:13 p.m., the NHA (Nursing Home Administrator) was advised of the finding and interview with staff member D. The Treatment Administration Record (TAR) was reviewed for the month of February 2021 which indicated that the splint had been placed on the resident's left wrist at 9:00 a.m. for 2/1, 2/2 and 2/3/21 when in actuality the resident was observed with no splint throughout the survey. On 02/04/21 at 12:54 p.m., an interview was conducted with the Director of Nursing regarding the facility's expectation on accuracy of documentation. She explained that her expectation was not to document that a splint was placed on a resident when it was not. Her expectation was to follow the plan of care for the resident. Event ID: Facility ID: 105286 If continuation sheet Page 2 of 6 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 105286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartow Center 2055 E Georgia St Bartow, FL 33830 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 Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility did not ensure post fall neurological checks were completed for one (Resident #234) of four residents sampled for falls. Findings included: A review of Resident #234's medical record revealed that he was admitted to the facility on [DATE] with diagnoses of COVID-19, difficulty walking, and muscle weakness. A review of the resident's care plan revealed that the resident was at risk for falls or fall related injury due to deconditioning and gait/balance problems. Interventions included remind resident and reinforce safety awareness, provide environmental adaptations, and anticipate and meet the resident's needs. A review of the progress notes dated 02/01/2021 at 4:47 a.m., revealed that the resident was found on the floor of his room, laying on his right side near the window around 2:15 a.m. He was assessed by the nurse and had no complaints of pain or discomfort. The resident suffered a skin tear to the top of his right hand, which was treated by the nurse. He was assisted back to bed and neurological checks were started. An interview was conducted on 02/04/2021 at 2:10 p.m. with the facility's Risk Manager (RM). The RM stated that the resident was found on the floor of his room by the window by staff. He was assessed by the nurse following the fall and was found to have no injuries except for a small skin tear to the back of his right hand. The resident was placed on neurological checks because the fall was not witnessed by staff. The RM stated that she was not able to locate the neurological checks for Resident #234. An interview was conducted on 02/04/2021 at 3:12 p.m. with the facility's Staff Development Coordinator (SDC). The SDC stated that she was Resident #234's nurse when he fell on [DATE]. He had an unwitnessed fall around 2:15 a.m. and was assessed for injuries after the fall. The resident had no apparent injuries except for a small skin tear to the top of his right hand. The SDC stated that the resident was started on neurological checks, which were continued throughout the shift and passed on to the next shift. The SDC stated that Resident #234's neurological checks could not be located in the binder that they were normally kept in. An interview was conducted on 02/04/2021 at 4:07 p.m. with the facility's Director of Nursing (DON). The DON stated that if a resident had an unwitnessed fall, neurological checks were started and the resident would be assessed by the nurse to verify that there was no injury sustained. The DON also stated that Resident #234's neurological checks could not be located in his chart or in the binder where they were normally kept. The DON stated that neurological checks should have been started following the resident's unwitnessed fall, but the record could not be located. A review of the facility policy titled, Neurological Evaluation, dated February 2020, revealed that a neurological assessment would be completed when a resident had experienced a change in level of consciousness, after a fall with a known head injury, or after an unwitnessed fall. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105286 If continuation sheet Page 3 of 6 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 105286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartow Center 2055 E Georgia St Bartow, FL 33830 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to provide post-dialysis assessment to one (Resident #26) of one resident sampled for dialysis. Residents Affected - Few Findings included: A review of Resident #26's medical record revealed that the resident was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and dependence on renal dialysis. A review of the care plan revealed that the resident had renal failure and was on hemodialysis. Interventions included communication and coordination with dialysis center regarding care plan goals, observe for signs and symptoms of infection, injury at access site, and observe dialysis site for signs and symptoms of bleeding. A review of the Physician's Orders revealed an order, dated 02/02/2021, to document vital signs upon returning from dialysis for monitoring. A review of the Dialysis Communication Forms, dated 01/04/2021 and 01/06/2021, revealed under the section titled, Facility Nurse Completes This Section:, no documentation. The sections for documenting the resident's vital signs, assessment of access site, assessment of dressing, and mental status assessment contained no documentation. A review of the facility policy titled, Dialysis Management, dated February 2020, revealed under the section Guidelines, that staff were to complete the Dialysis Communication Tool before and after dialysis and follow up on any special instructions from the dialysis center. The policy also revealed that staff were to evaluate for and manage post dialysis complications which may include, but were not limited to confusion, fever, pruritus, anaphylaxis, seizures, hypotension, muscle cramps, cardiac arrhythmia, restlessness, air embolus, insomnia, and hemorrhage. An interview was conducted on 02/04/2021 at 4:24 p.m. with Staff G, Licensed Practical Nurse (LPN). Staff G, LPN stated that the Dialysis Communication Tool was filled out by the nurse at the facility before the resident left for dialysis and after the resident returned to the facility from dialysis. The facility nurse would document an assessment of the dialysis site as well as assessment of vital signs upon return to the facility. Staff G, LPN stated that all entries on the Dialysis Communication Tool should be filled in completely and no areas of the form should be left blank. An interview was conducted on 02/04/2021 at 4:35 p.m. with the Director of Nursing (DON). She stated that the nurses complete the post dialysis assessments on the Dialysis Communication Tool when a resident returned from dialysis. Nurse's should be filling out the form and documenting the assessments completely. The DON stated that nursing staff should monitor the resident's dialysis site when they return to the facility and document the assessment on the Dialysis Communication Tool. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105286 If continuation sheet Page 4 of 6 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 105286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartow Center 2055 E Georgia St Bartow, FL 33830 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility did not ensure that four vials of Lorazepam 2 mg/ml solution, a controlled substance, was kept in a separately locked, permanently affixed compartment inside of the refrigeration unit. Findings included: On 2/04/21 at 11:50 a.m., the medication storage room for the 100 hall and 200 hall was observed with Staff A, LPN. The medication room was entered, and immediately across from the door was a small refrigerator. The refrigerator had a key lock on the left side. Staff A, LPN used a key to open the lock. Inside the refrigerator was a large plastic container approximately eleven inches long, seven inches wide, and two inches deep. Staff A, LPN said that this was the EDK (Emergency Drug Kit). Attached to the top of this plastic box with hook and loop fasteners was another small plastic box that was the size of a standard deck of playing cards that contained four vials of Lorazepam 2 mg/1 ml. The large plastic container was taken out of the refrigerator and placed on the counter. The small plastic box containing the Lorazepam was easily removed. Staff A, LPN then proceeded to open a gray metal lock box that was approximately seven inches long and six inches wide that was permanently affixed to the shelving of the refrigerator. The shelving of the refrigerator could not be removed. The lock box was empty. Staff A, LPN confirmed that the small plastic box contained four vials of Lorazepam 2 mg/1 ml and that the Lorazepam should have been placed in the locked box. Staff A, LPN stayed in the medication room with the unlocked medications while a member of administration could be located. Staff B, Regional Nurse, walked up and asked if she could be of assistance. She walked into the medication room and was shown the EDK, which included the small box of unsecured narcotics. She said, The lock box is right there. Staff A, LPN took the unsecured narcotics, put them into the lock box, and locked it. When asked what her expectation was of the narcotic refrigerated EDK, the regional nurse said it should be in the lock box At 12:55 p.m., in an interview with the DON (Director of Nursing), she said that refrigerated controlled substances should be kept in a lock box. In a policy and procedure given by the facility titled, Controlled Medication Storage dated 11/2017, the policy read, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special ., storage Under procedures, #4 reads Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. Consultant Pharmacist interview was attempted without success on 2/05/2021 at 9:36 a.m. and 3:58 p.m. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105286 If continuation sheet Page 5 of 6 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 105286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bartow Center 2055 E Georgia St Bartow, FL 33830 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, interviews, record review and policy review the facility failed to maintain a complete and accurate medical record for one (Resident #63) of 34 sampled residents related to inaccurate documentation for the application of a left hand splint. Findings Included: A review of the plan of care for Resident #63 for range of motion, revealed that she had a risk of actual limitations as evidenced by impairment on one side left hand/wrist date initiated 1/28/21. As an intervention the resident should have an adaptive device: left hand wrist splint; apply to left hand. A review of the physician's order read: remove before/after lunch or other, dated 1/28/2021. May remove for skin sweep on 7-3. A review of the MAR (Medication Administration Record) dated from 2/1/21 to 2/28/21 indicated that the splint was applied after breakfast. One time a day monitor for redness, skin irritation, and discomfort. The MAR indicated that Resident #63 had her hand splint applied 2/1, 2/2, and 2/3/21 at 9:00 a.m. The observations were conducted throughout the survey as follows: On 02/02/21 at 1:33 p.m., the resident did not have a splint on her left hand. On 02/03/21 at 10:56 a.m., the resident was observed sleeping in bed with no splint on her left hand. On 2/04/21 at 12:12 p.m., the resident did not have a splint on her left hand. She stated, the splint was in her top drawer. An interview was conducted with the resident's CNA (Certified Nursing Assistant) staff member D, he stated he had not seen a splint for the resident. He was regularly assigned to the resident. On 02/04/21 at 12:13 p.m., the NHA (Nursing Home Administrator) was advised of the finding and interview with staff member D. The Treatment Administration Record (TAR) was reviewed for the month of February 2021 which indicated that the splint had been placed on the resident's left wrist at 9:00 a.m. for 2/1, 2/2 and 2/3/21 when in actuality the resident was observed with no splint throughout the survey. On 02/04/21 at 12:54 p.m., an interview was conducted with the Director of Nursing regarding the facility's expectation on accuracy of documentation. She explained that her expectation was not to document that a splint was placed on a resident when it was not. Her expectation was to follow the plan of care for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105286 If continuation sheet Page 6 of 6