Inspection·April 8, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility provided a policy titled, Notification of Resident/Patient Change in Condition, effective October 2021. The procedure identified staff would Notify the Physician resident/resident representative, and case management when indicated, if there is a significant change in condition, regardless of the time of day. A review of Resident #36's Order Listing Report identified a physician order, dated 3/11/22, for staff to obtain an accucheck two times a day for DM2 (Diabetes Mellitus 2), if less than 60 or greater than 400 contact physician. A review of the April 2022 Medication Administration Record (MAR) indicated the resident was to be administered Humulin 70/30 Suspension 15 units subcutaneously two times a day for DM related to Type 2 Diabetes Mellitus with diabetic chronic kidney disease. The order for Humulin insulin was started on 1/11/22. The April MAR for Resident #36 identified staff did not document blood glucose levels twice a day at 6:00 a.m. and 4:30 p.m. as scheduled. The March 2022 MAR identified staff did not document blood glucose levels twice a day at 6:00 a.m. and 4:30 p.m. as scheduled. The MAR did not indicate blood glucose levels were documented with the administration of Humulin insulin. The Blood Sugar Summary, dated 4/8/22, for Resident #36 indicated staff had documented one time a day blood glucose levels on 3/1/22 - 3/7/22, 3/9/22-3/10/22, 3/14/22-3/16/22, 3/18/22-3/19/22, 3/26/22, 3/29/22, 4/3/22, and 4/4/22. Staff documented twice daily blood glucose levels on 3/21/22. During an interview on 4/8/22 at 3:44 p.m., the DON reviewed the physician order for Resident #36 instructing staff to obtain the resident's blood glucose levels twice daily, reviewed the Blood Glucose Summary, and reviewed the resident's March and April MARs. She confirmed staff were not documenting blood glucose levels consistently and the order should have supplemental space to document the values. A policy titled, Physician Orders, effective October 2021, identified that At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. The procedure indicated, Medications that require monitoring will need to be entered into the electronic medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete 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 04/08/2022 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure physician ordered laboratory work was obtained for one resident (#90) out of thirty-five sampled residents. Residents Affected - Few Findings included: A review of the admission Record revealed Resident #90 was admitted on [DATE]. The admission Record included diagnoses of unspecified chronic kidney disease, unspecified chronic obstructive pulmonary disease (COPD), and other seizures. An interview was conducted on 4/5/22 at 12:01 p.m. with Resident #90 lying flat in bed and wearing a nasal cannula that was delivering 2 liters of oxygen per minute. The resident reported to having a grand mal seizure last week. A review of Resident #90's February and March 2022 Medication Administration Records (MAR) identified the resident had a physician order for: - Depakote Tablet Delayed Release (Divalproex Sodium) - Give 500 mg (milligram) by mouth two times a day for Epilepsy. Check for Depakote levels. Dated 9/29/2021. - Levetiracetam Tablet 750 mg - Give 1 tablet by mouth two times a day for SEIZURE. Dated 5/14/21. The February 2022 Treatment Administration Record (TAR) indicated the following: - CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Levetiracetam level, (and) Depakote level every 4 month(s) starting on the 20th for 1 day. Ordered 10/20/21. The February 2022 TAR indicated Resident #90's laboratory bloodwork was scheduled and administered during the night shift on 2/20/22 and the day shift on 2/21/22. A review of Resident #90's medical record did not include any CBC, CMP, Levetiracetam and Depakote laboratory levels from 2/20/22 or 2/21/22. A review of an electronic transfer form for Resident #90 identified the reason for the transfer was due to seizure activity. The March 2022 TAR indicated a CBC, CMP, TSH (Thyroid-Stimulating Hormone), Lipids, Vitamin D2, Hydroxy, Keppra level, and Depakote level was ordered for one day on Thursday 3/24 and Friday 3/25/22. A review of the blood work obtained from Resident #90 on 3/26/22 included Vitamin D, CBC, TSH, CMP, and Keppra levels. The report did not include the resident's Depakote level. On 4/8/22 at 1:00 p.m. the Director of Nursing (DON) stated the laboratory bloodwork scheduled for February 2022 was not drawn. She confirmed staff had signed off on the February MAR that the lab work had been done. She confirmed the March results did not include the resident's Depakote level. A review on 4/8/22 at 3:36 p.m. of Resident #90's active physician orders identified a STAT (immediate) order for a Depakote level scheduled for 4/8/22. (continued on next page) 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 04/08/2022 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 0770 The facility's policy titled, Lab Process, undated, indicated the process as follows: Level of Harm - Minimal harm or potential for actual harm - 1. Obtain the order for labs from the MD (medical doctor). - 2. Complete the lab log sheet in the lab book. Residents Affected - Few - 3. Complete the Requisition sheet and place it behind lab log sheet under the day the lab should be drawn. - 5. Upon receiving the results notify the MD and RP (Responsible Party) of results and file the lab in the medical record under LABS. - 6. Document the labs you received and reported to include any additional follow up in a progress note. 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 04/08/2022 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to identify a possible entrapment zone between the headboard and mattress for one resident (#41) out of 104 residents. A facility-wide audit identified a total of seven bed frames and mattresses that had to be replaced or adjusted. Findings included: An observation was conducted on 4/5/22 at 1:49 p.m. of Resident #41 lying in bed. The observation revealed the mattress was lying flat on the bed frame and two mattress prongs were exposed. A gap between the mattress and headboard measured five inches. (Photographic Evidence Obtained) On 4/6/22 at 8:55 a.m. the Director of Nursing (DON) viewed the mattress and headboard and stated a facility-wide review would be conducted of mattresses and bed frames. She identified the certified nursing assistants (CNAs) do room changes and the facility bought bed frames and mattresses separately so probably the frame Resident #41 had now may not have had a mattress; so they moved the mattress that had been used to the new frame. The DON stated not all the frames in the facility are able to be adjusted and staff were being educated that if they notice the mattress does not fit the frame, and they don't know how to adjust it, they needed to ask for assistance due to the safety of the resident. A facility census, dated 4/5/22 and printed at 2:04 p.m., identified mattresses that were replaced and what bed frames that had to be adjusted. The census showed Resident #41's bed frame had to be adjusted. This census was signed by the Physical Plant Consultant on 4/5/22. On 4/8/22 at 3:00 p.m. the Nursing Home Administrator (NHA) viewed Resident #41's mattress and bed frame. The NHA stated she did not know about the resident's mattress. The Senior Maintenance Director stated, at 2:33 p.m. on 4/8/22, during inspections maintenance makes sure the mattresses fit the bed or was torn. The Senior Maintenance Director stated [Resident #41's] mattress was a 76 inch mattress and not an 80 inch. The Senior Maintenance Director and NHA stated most mattresses have been exchanged for 80 inch mattresses. A review of the admission Record showed Resident #41 was admitted on [DATE]. The admission Record included diagnoses to include paranoid schizophrenia, presence of cerebrospinal fluid drainage device, and unspecified bipolar disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #41's Brief Interview of Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. The MDS indicated the resident required supervision of one person for bed mobility and supervised after set up for transfers between surfaces. The care plan, initiated on 4/29/20 and revised on 11/9/20, for Resident #41 identified the resident was at risk for falls or fall related injury because of: History of Fall prior to admission, History of Previous Fall, (and) Unaware of safety needs. The interventions instructed staff to remind resident and reinforce safety awareness and anticipate and meet the resident's needs. (continued on next page) 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 04/08/2022 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 0909 The instructions for Beds -Electric documented the steps as: Level of Harm - Minimal harm or potential for actual harm Inspect all beds for all gaps that are not correct. Beds must be checked prior to a new admission and as directed by DON (Director of Nursing). Residents Affected - Few Complete task at least quarterly or more often as required. The documentation indicated the task had last been completed on-time on February 7, 2022. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105286 If continuation sheet Page 6 of 6