Health inspection·November 20, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 11/20/2023 at 12:15 PM with Resident #5. The resident stated no one had followed up or spoken to him regarding the grievance on 11/03/2023. An interview was conducted on 11/20/2023 at 12:30 PM with Resident #8. The resident stated she was not aware of any follow-up to the grievance on 10/13/2023. Residents Affected - Few A review of the facility's policy and procedures titled Grievance, with a revision date of 2016, revealed the following: Policy: The facility will promptly and responsibly investigate these grievances to initiate timely resolution and determine if the facility has areas that need correction to achieve the goal of providing quality of care and a safe environment. The facility will consider a grievance and opportunity to enhance care and services. Procedures: 6. The grievance official will make every attempt to resolve the grievance in a timely manner and will keep the resident and or their representative aware of the progress towards resolution. The resident or representative will be notified of the result of the grievance and may receive a written decision regarding his or her grievance if requested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 2 of 7 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 11/20/2023 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation was complete and accurate for two residents (#1 and #3) of three sampled residents for resident record documentation. Findings included: Resident #1 was admitted to the facility on [DATE], with a diagnosis included but not limited to, fracture of the T7 (thoracic vertebrae 7), T8, T11, and T12, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type 2 (DM), respiratory failure, congestive heart failure (CHF), atrial fibrillation (A-Fib), depression, Bipolar disorder, GERD (Gastro-esophageal reflux disease), and hypertension (HTN). Review of the physician orders and Medication Administration Record (MAR) for October 2023 showed the following documentation missing: Gabapentin 300 milligrams (mg) at bedtime for neuropathy on 10/27/23 Pantoprazole Sodium delayed release 40 mg daily for GERD on 10/26 and 10/27/23 Risperidone 3 mg at bedtime for Bipolar disorder on 10/27/23 Trazodone HCL 50 mg at bedtime for depression on 10/27/23 Dabigatran Elexilate Mesylate 150 mg every 12 hours for atrial fibrillation at 2100 on 10/27/23 Lispro insulin 30 units before meals for diabetes at 0630 on 10/23, 10/26, 10/27/23 Oxygen at 2 liters / minute via nasal cannula on every shift on 10/26/23 at 11 p.m. Vital signs every shift on 10/29/23 on days; on 10/25 and 10/26 on evenings; on 10/22, 10/26 and 10/31 on night shift Glucose 15 mg oral gel 40% give 1 kit by mouth as needed for low blood sugar less than 60 if resident is awake, on 10/28/23 and 11/02/2023. Glucagon Emergency Injection Kit 1 mg subcutaneous as needed for low blood sugar less than 60 on 10/28/23. Review of Resident #1's care plans showed he had altered cardiovascular status related to atrial fibrillation, altered endocrine status related to diabetes, used psychotropic medications related to depression and Bipolar disorder, and had pain related to neuropathy. His interventions included but were not limited to administer medications per MD (medical doctor) orders. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. She was hospitalized from [DATE] to 11/02/23 and 11/07/23 to 11/16/23. Diagnoses included but not limited to acute and chronic respiratory failure, COPD, CHF, pneumonia, A-Fib, and HTN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 3 of 7 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 11/20/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Review of the physician orders and Medication Administration Record (MAR) for October 2023 showed the documentation was not consistent regarding the time she was in the hospital from [DATE] to 11/01/23. Review of the physician orders and Medication Administration Record (MAR) for November 2023 showed the documentation was not consistent regarding the time she was in the hospital from [DATE] to 11/16/23. Residents Affected - Few During an interview on 11/20/2023 at 1:39 p.m. the Director of Nursing (DON) verified there was lack of consistent documentation in the October and November MARS for both Resident #1 and #3. She stated she would get with the nurses. She stated the lack of documentation comes up on the dashboard. The DON stated the Unit Managers are supposed to monitor for lack of documentation daily. Review of the facility's Policy titled Medication Administration - General Guidelines, effective 2019, showed the following: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures: D. Documentation (including electronic) 1) the individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 6) if a dose of regularly scheduled medications is withheld, refused, no available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If consecutive doses of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. 7) if an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters .are described in the system's user manual. These procedures should be followed and ma differ slightly from the procedures for using paper MARS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 4 of 7 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 11/20/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by: 1) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, 2) failing to ensure appropriate signage was posted outside of a resident room under transmission based precautions for one resident (#2) of two residents sampled for transmission based precautions, and 3) failing to ensure physician's orders for transmission based precautions were in place in a timely manner for one resident (#3) of two residents sampled for transmission based precautions. Residents Affected - Few Findings included: An observation was conducted on 11/20/2023 at 10:05 AM outside of Resident #2's room. An isolation caddy was observed outside of Resident #2's room with signage posted on the caddy that Resident #2 was on droplet precautions. The posted signage revealed instructions for any essential personnel entering Resident #2's room to perform hand hygiene and don an isolation gown, N95 respirator, eye protection (face shield or goggles), and gloves before entering the resident's room. Staff A, Registered Nurse (RN) was observed exiting another resident's room and entering Resident #2's room. Staff A, RN was observed wearing a surgical mask. Staff A, RN did not don an isolation gown, N95 respirator, eye protection, or gloves before entering Resident #2's room. An interview was conducted with Staff A, RN after she exited Resident #2's room. Staff A, RN observed the signage posted on the isolation caddy outside of Resident #2's room and stated staff should don gloves, an N95 mask, eye protection, and an isolation gown before entering the resident's room. Staff A, RN stated she did not realize the resident was on transmission based precautions and she did not see the isolation cart outside of Resident #2's room. Staff A, RN stated she should have donned the appropriate PPE before entering Resident #2's room. An observation was conducted on 11/20/2023 at 10:45 AM outside of Resident #2's room. Staff B, Certified Nursing Assistant (CNA) and Staff C, CNA were observed donning PPE before entering Resident #2's room. Both staff members donned an isolation gown, an N95 mask, and gloves before entering the room. Both Staff B, CNA and Staff C, CNA were wearing eye glasses, but did not don a face shield or goggles before entering Resident #2's room. An interview was conducted with Staff B, CNA after she exited Resident #2's room. Staff B, CNA stated Resident #2 was under droplet isolation precautions due to having an infected wound and staff were to don an isolation gown, N95 mask, gloves, and eye protection before entering the resident's room. Staff B, CNA also stated her eye glasses were able to be used as appropriate eye protection stating, It covers your eyes. A review of Resident #2's medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of osteomyelitis, cellulitis, and a methicillin resistant staphylococcus aureus (MRSA) infection. A review of Resident #2's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 11/13/2023, revealed under Section F: Infection Control Issues, Resident #2 had a MRSA infection in the toe bone and was under contact isolation precautions. A review of Resident #2's physician's orders revealed an order, dated 11/17/2023 for contact isolation precautions due to a MRSA infection in a wound until 12/18/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 5 of 7 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 11/20/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 11/20/2023 at 10:56 AM with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN stated Resident #2 had the wrong signage posted outside of his room because the resident was on contact isolation precautions and not droplet isolation precautions. Staff D, LPN stated, They must have not had the right sign when Resident #2 was admitted to the facility but he did not know for sure because he was not in the facility when Resident #2 was admitted . During the interview, the facility's Director of Nursing (DON) was observed at the unit nurse's station with two contact precautions signs. The DON stated the signage outside of Resident #2's room was incorrect and the resident should have had signage indicating he was on contact isolation and not droplet isolation. A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE], with a readmission date of 11/16/2023, with diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD), and COVID-19. A review of Resident #3's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 11/16/2023, revealed under Section F: Infection Control Issues, Resident #3 had a clostridium difficile (c. diff) infection in the stool and was under contact isolation precautions. A review of Resident #3's physician's orders revealed an order, dated 11/20/2023, for contact isolation precautions for 10 days, ending on 11/26/2023. Review of Resident #3's physician's orders did not reveal a physician's order for contact isolation precautions prior to 11/20/2023. An interview was conducted on 11/20/2023 at 1:40 PM with the facility's Assistant Director of Nursing (ADON) and Infection Preventionist (IP). The IP stated facility staff should know the reason a resident is on transmission based precautions and a physician's orders for the precautions should be in place in the resident's record. The IP stated staff should don an isolation gown, an N95 mask, gloves, and eye protection before entering the room of a resident under droplet isolation precautions. The IP stated eye glasses are not considered eye protection and staff should be utilizing the provided goggles to ensure their eyes are protected. A review of the facility policy titled Isolation - Notices of Transmission-Based Precautions, last revised in August 2019, revealed the following: Policy Statement notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation when transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for any type of precautions. A review of the facility policy titled Isolation - Categories of Transmission-Based Precautions, last revised in October 2018, revealed the following: Policy Statement transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation contact precautions may be implemented for residents known (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 6 of 7 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 11/20/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room. Droplet precautions may be implemented for an individual documented or suspected to be infected with microorganism transmitted by droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning. Masks will be worn when entering the room. Gloves, gown, and goggles should be worn in the room if there is risk of spraying respiratory secretions. (Photographic evidence was obtained). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105301 If continuation sheet Page 7 of 7