Health inspection·June 28, 2023

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 02/24/23 This nurse noticed patient was masturbating at the nursing station in the middle of two other patient[s]. Patient was redirected to his room. Patient come back later in the hours and stood behind patient and done the same behavior. The progress note dated 02/24/23 was written by Staff B, Licensed Practical Nurse (LPN). On 06/26/23 at 1:24 p.m., an interview was attempted via phone. No answer. The progress note dated 03/12/23 was written by Staff C, LPN. On 06/16/23 at 1:27 p.m., Staff C, LPN stated the last time she worked with Resident #4 one of the Certified Nursing Assistants (CNAs) reported to her she saw the resident with another female. He was grabbing her chest and he kissed her on the cheek. Staff C did not recall any other incidents. She stated the resident was not easily redirected. The progress note dated 04/11, 04/14, and 05/12/23 was written by Staff A, LPN. On 06/26/23 at 2:17 p.m., an interview was attempted via phone. No answer. The progress note dated 05/10/23 was written by Staff D, LPN. On 06/26/23 at 3:30 p.m., the Administrator reported Staff D, LPN, did not know anything about the incident. Staff D, LPN, reported she didn't witness anything at all. She stated a CNA told her about the incident, but she didn't remember who the CNA was. The Administrator stated this nurse should have reported abuse. She was agency staff. On 06/26/23 at 3:41 p.m. in a telephone interview with Staff D, LPN, she stated she had worked with Resident #4 two times. One time she documented something, and it was that he was masturbating while touching a female resident's breast. Staff D did not remember who the CNA was that reported this concern to her. The CNA just told her she needed to document something related to the incident. On 06/26/23 at 1:20 p.m., an interview was conducted with the Administrator, Director of Nursing (DON), and Risk Manager. The DON stated when she questioned Staff A, Licensed Practical Nurse (LPN), about the progress note written on 04/14, the nurse stated Resident #4 was grabbing at the resident although the note indicated an inappropriate sexual act was being performed. The Administrator stated she could not remember the name of the female resident. The Risk Manager stated he would have to find more information about the progress note written on 04/11 because he was unaware of the incident. The Risk Manager stated no one was touched during the incident on 04/14. It was mostly about Resident #4 masturbating. He did not know the female resident involved in the incident. The Risk Manager stated he did not recall the incident on 05/10. The Administrator stated per the progress note, the incident should have been reported and investigated if that's what happened. The Risk Manager stated he could not remember the incident on 05/12. He stated he spoke to Staff A, LPN, and asked him why he did not tell them about the incident. The Abuse, Neglect, Exploitation, and Misappropriation policy undated and provided by the facility revealed the following: Policy It is the policy of this facility to take appropriate steps to prevent abuse and to ensure that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Services Director, and the Director of Nursing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 2 of 3 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 105301 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Valencia Hills Health and Rehabilitation Center 1350 Sleepy Hill Rd Lakeland, FL 33810 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 0610 7. Investigation Level of Harm - Minimal harm or potential for actual harm A thorough investigation will be conducted. The Abuse Coordinator/ designee will initiate procedures for conducting the investigation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 3 of 3