Health inspection·October 21, 2021

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy, record review, resident and staff interviews, the facility failed to provide the necessary services to maintain personal hygiene for 2 (Resident #24 and #49) of 3 residents sampled for activities of daily living (ADLs). Residents Affected - Few The findings included: The facility policy AM Care (updated 10/19) specified, To assist patient with morning care in preparation for daily activities while protecting the patient's right to personal choice . 1. The Annual Minimum Data Set (MDS) with a reference date of 8/1/2021 noted Resident #24 had a diagnosis of dementia and scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The care plan revised on 11/20/2020 documented Resident #24 required assistance at times and instructed staff to assist with bathing, showering, daily hygiene, grooming, dressing, and oral care as needed. On 10/18/21 at 1:10 p.m., during an observation Resident #24 was in his room and was dressed in his own clothing. The resident did not respond to questions. The room had a pungent odor. Resident #24 was unkempt with fingernails extending approximately ½ inch past the tip of the fingers with a brown substance under the nails. The resident had stubble facial hair growth of approximately three to four days. The bed was unmade, and the bed linen had multiple brown stains. *Photographic Evidence Obtained* On 10/19/21 at 9:23 a.m., and 10/20/21 at 8:20 a.m., during observation, Resident #24 was dressed in the same clothing as observed on 10/18/21. The resident was unshaven, and his fingernails were long with a brown substance under the nail beds. The bed linen on the bed remained stained. On 10/19/21 at 9:35 a.m., in an interview Registered Nurse (RN) Supervisor Staff R said Resident #24 required assistance with bathing and dressing, and encouragement for hygiene. On 10/20/21 at 8:30 a.m., in an interview, Certified Nursing Assistant (CNA) Staff B said she was frequently assigned to care for Resident #24 and knew him very well. CNA Staff B said, sometimes the resident refuses to let me give him care or showers. When he refuses, I document it and I tell the nurse. On 10/20/21 at 8:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said if the resident refused care, sometimes she would go and try to encourage him. She said the resident had a right to refuse care. On 10/20/21, a review of the CNA documentation for 10/1/21 through 10/20/21 documented Resident #24 refused showers on 10/1/21, 10/4/21, 10/8/21, and 10/15/21. There was no documentation in the clinical record of refusal of care or the interventions attempted when Resident #24 refused showers. On 10/20/21 at 12:01 p.m., in an interview, the Director of Nursing (DON) said if the resident was refusing care and bathing, the nurse should speak to the resident, offering encouragement, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 2 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few document the refusal of care in the clinical record. The DON said the facility had a responsibility to the residents to provide care. On 10/20/21 at 12:23 p.m., in an interview, LPN Staff C said Resident #24 was provided a shower and clean bed linen. LPN Staff C confirmed the bed linen was visibly soiled and said, they were disgusting. LPN Staff C confirmed Resident #24 had a pungent body odor and required Activities of Daily Living care. On 10/20/21 at 1:52 p.m., in an interview, the DON confirmed the CNA documentation showed Resident #24 refused 4 showers since 10/1/21. The DON said, well he refuses, and we care plan it. The DON said the process when a resident refused care was for the CNA to tell the nurse. The nurse should try to encourage the resident to bathe and if refused, they documented it. The DON confirmed there was no documentation of interventions attempted for Resident #24 when he refused bathing and ADL care. 2. On 10/19/21 at 1:00 p.m., Resident #49 was out of bed in a chair and dressed in his own clothing. A review of the clinical record for Resident #49 revealed a care plan. indicating the resident had an ADL self-care deficit and required assistance. The interventions for the resident's care instructed staff to assist with daily hygiene, grooming, dressing, and oral care as needed. On 10/20/21 at 8:20 a.m., during an observation, Resident #49 was in bed eating breakfast and was dressed in the same clothing as 10/19/21. On 10/20/21 at 8:30 a.m., in an interview CNA Staff B said Resident #49 never refused care and was dependent for dressing. CNA Staff B said the night shift CNA would be responsible to provide ADL care and change the resident into pajamas for sleep. CNA Staff B said she had not dressed Resident #49 yet and had provided him with the breakfast tray. On 10/20/21 at 8:48 a.m., in an interview with the night shift, LPN Staff G said the CNAs were required to assist the residents to bathe and change clothing, but they had a right to refuse. LPN Staff G said she was not aware Resident #49 was dressed in the same clothing and had not received assistance for bed/sleep. LPN Staff G said sometimes she would check to ensure the CNAs were changing residents and preparing them for bed. On 10/20/21 at 12:03 p.m., in an interview, the DON said it was the CNAs responsibility to ensure Resident #49 was dressed for bed. On 10/20/21 a review of the CNA documentation for the 3-11 and 11-7 shifts on 10/19/21 through 10/20/21 at 7:00 a.m., documented Resident #49 had received assistance with personal hygiene including dressing. On 10/20/21 at 1:46 p.m., in an interview the DON confirmed the CNA had documented on 3-11 and 11-7 shifts, dressing assistance was provided to Resident #49. The DON said, well sometimes, the CNA will remove the soiled clothing and leave it on the chair next to the bed or at the foot of the bed and the next shift will come in and not know it and put the same clothing back on the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 3 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #74's medical records revealed a Significant Change Minimum Data Set (MDS) Assessment with a reference date of 9/22/21, noting the resident's activity preference included books, listen to music, be around animals such as pets. Residents Affected - Few On 10/18/21 at 1:06 p.m., Resident #74 was observed lying in bed, eyes closed. The same observation was made on 10/19/21 at 1:00 p.m. On 10/19/21 at 3:00 p.m., in an interview Resident #74 said, I have my eyes closed, thinking most of the time. On 10/19/21 at 4:22 p.m., in an interview the Interim Director of Nursing said, We do not have an activity director. On 10/20/21 at 9:00 a.m., in an interview Resident #74 said, There is no activity calendar posted in the room, there is nothing to do here. Based on observation, record review, staff and resident interview, the facility failed to provide an ongoing program of activities designed to meet the interest and support the well-being of 2 (Resident #57 and #74) of 3 residents reviewed for activities. The findings included: The facility policy for Communal Dining and Activities dated 04/30/21, Copywrite 2021 ProMedica Health System read, . Review the number of patients with a current interest in the program scheduled i.e., Bingo which is a Cards/game interest. If the report reflects more patients with an interest in Cards/games that any room can hold based upon proper social distancing of six (6) feet, consider scheduling two or more activities of the same program type. 3. Fully vaccinated patients - Patients may participate in activities without face covering or social distancing if all participating residents are fully vaccinated. 4. Unvaccinated patients . If unvaccinated patients are present during communal activities, then all patients must use face covering while participating in activity. Redesign seating arrangements to comply with social distancing and occupancy requirements . 1. On 10/18/21 at 4:20 p.m., Resident #57 was in her room, lying in bed. She said, they only play BINGO but it's not really BINGO. They put a card on your wall, and every day the staff come in to mark of some numbers. Resident #57 said she was bored; she had asked for other games, but nothing changed. On 10/19/21 at 9:50 a.m., Resident #57 was in her room sleeping. On 10/19/21 at 3:28 p.m., Resident #57 was in her room, lying in bed. She said Activity Assistant Staff N came into the room and marked off the BINGO numbers for the day. Resident #57 said that was all BINGO was: They hang a BINGO card on your wall and everyday someone comes in to mark off your numbers. She said the boredom was terrible because there were no activities to look forward to during the day. She said the facility did not have an Activity Director or an activity calendar for the month and it had been a while since the facility had activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 4 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 10/20/21 at 11:25 a.m., Activity Assistant Staff M said she started working at the facility four weeks ago. She said there had been no group activities in the activity room since she had been working at the facility. One staff member recently tested positive for COVID-19 therefore the residents could not get together. She explained the Activity Director quit in August 2021. Activity Assistant Staff N said in addition to activity duties, she was responsible for screening visitors and bringing residents to the front of the building for outside visits. She said that took up a lot of time. She said all she could do is distributing the Daily Chronicle to the residents for current events. On 10/21/21 at 12:58 p.m., the Administrator confirmed the Activity Assistant's duties included screening visitors for outdoors visits with residents. The Administrator said screening the visitors was a lot of work, and the process was very time consuming for the activity assistant. The Administrator confirmed the Activity Assistant might not have much time to contribute to resident activities. Review of Resident 57's Daily Recreational Activity Participation Documentation for September 2021 included BINGO. Resident #57 was independent for current events, movies, socializing, and television. Resident #57 had one visitor on 9/21/21 and her nails done on 9/1/21. Review of Resident #57's Daily Recreational Activity Participation Documentation for October 2021 included BINGO each day from 10/1/21 through 10/19/21. Resident #57 was independent for current events, movies, socializing, and television. Resident #57 had one visitor on 10/5/21 and 10/10/21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 5 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the clinical record for Resident #283 revealed a physician's order dated 10/19/21 to cleanse the sacral pressure ulcer with normal saline, apply skin prep (protective film to reduce friction) to the peri wound daily and as needed. Residents Affected - Few On 10/20/21 at 1:31 p.m., the sacral wound dressing change for Resident #283 was observed with Wound Care Registered Nurse (RN) Staff P and RN Staff Q assisting with the dressing change. RN Staff P did not apply the skin prep to the peri wound as per the physician's orders. On 10/20/21 at approximately 1:45 p.m., RN Staff P verified she failed to apply the skin prep as the order directed. RN Staff P signed off on the TAR she completed the wound care as per the physician's orders. Based on observation, review of facility policy, record review, and staff interview, the facility failed to have documentation of interventions as per the physician's order to treat and prevent the worsening of pressure ulcers for 1 (Resident, #332) of 3 residents reviewed for pressure ulcers. The facility failed to follow wound care orders for 1(Resident #283) of 3 residents reviewed for pressure ulcers. The findings Included: The facility's Skin Practice Guidelines HCR Healthcare LLC dated 2013 stated, .Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer . Weekly skin evaluations are completed by the licensed nurse for any other patient. Skin evaluations are documented in the clinical record . The facility's Documentation Guidelines dated 05/2021 stated, All medications ordered/ administered are documented on the Medication Administration Record. All treatments ordered/ completed are documented on the Treatment Administration Record. Clinical record review showed Resident #332 was admitted to the facility on [DATE] after left hip fracture surgery and discharged to an acute care hospital on 9/20/21. Resident #332's admission Braden Scale (tool for predicting risk for developing pressure injuries) dated 8/6/21 showed a score of 15 which indicated the Resident was at increased risk for pressure ulcers. The admission Minimum Data Set (MDS) assessment with a target date of 8/11/21 noted Resident #332 had one unstageable (Covered by extensive dead tissue) pressure ulcer that was present on admission. Resident #332's physician's order summary included a physician's order dated 8/9/21 to float heels (remove all contact between the heel and bed) when in bed, heel protectors when in bed, and to apply betadine (antiseptic solution used to treat or prevent skin and wounds infections) to left heel with deep tissue injury every shift for wound care. Resident #332's care plan, (individualized treatment plan to address resident's needs), included as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 6 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0686 of 8/9/21 interventions to elevate heels as able and heel protectors when in bed as ordered. Level of Harm - Minimal harm or potential for actual harm The care plan for the left heel deep tissue injury to the left heel dated 8/10/21 included to administer treatment per physician orders, elevate heels as able, encourage and assist as needed to turn and reposition, pressure reducing surface on bed and wheelchair. Residents Affected - Few Resident #332's care plan documented he required extensive assistance of two staff members to transfer from bed, had urinary incontinence and mobility deficit. Review of the Treatment Administration Record (TAR) for August and September 2021 failed to show documentation the resident's heels were floated, heel protectors applied, and betadine applied on the evening shift of 8/9/21, 8/10/21, 8/12/21, 8/25/21, 8/28/21, 8/30/21, 9/1/21, 9/3/21, 9/4/21, 9/9/21 and 9/17/21. The TAR for August and September 2021 lacked documentation the Resident's heels were floated, heel protectors applied, and betadine applied on the night shift of 8/9/21, 8/11/21, 8/12/21, 8/28/21 and 9/16/21. The TAR for September 2021 lacked documentation the left heel was floated, heel protectors applied, and betadine applied on the day shift of 9/4/21 and 9/10/21. On 10/20/21 at 11:15 a.m., in an interview Registered Nurse (RN) Staff H said the staff assessed skin and applied skin prep as a preventative measure and if a wound opened, they communicated with physician and they applied betadine, after it had been ordered, to help dry out the wound. The staff offloaded the feet with pillows and if ordered protective boots were applied. RN Staff H said the nurse was responsible for documenting the treatments in the TAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 7 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, record review and staff interview, the facility failed to have documentation of consistent catheter care and ensure the proper placement of the urinary catheter drainage collection bag to reduce potential complications for 1 (Resident #19) of 1 sampled resident with indwelling catheter. The findings included: Review of the facility's ongoing management strategies Indwelling catheters (2012 HCR Healthcare LLC) noted .Strategies to prevent UTI (Urinary Tract Infection) . Keep collection bag below the level of the bladder. Routine meatal care . Review of the clinical record for Resident #19 revealed a physician's order dated 6/27/21 for a Foley catheter (Catheter placed in the bladder to drain urine) for urinary retention and Foley catheter care every shift. Review of the care plan for use of indwelling urinary catheter revised on 6/28/21 revealed a goal for no acute complications of urinary catheter use. The interventions included to provide catheter care and maintain drainage bag below bladder level. On 10/18/21 at 10:45 a.m., Resident #19 was observed in a low bed. The urinary catheter drainage collection bag was on the seat of wheelchair next to the bed above bladder level. *Photographic Evidence Obtained* On 10/19/21 at 9:17 a.m., Resident #19 was observed in bed. The urinary catheter drainage collection bag was on the floor. *Photographic Evidence Obtained* On 10/20/21 at 9:21 a. m., Resident #19 was observed in the wheelchair. The urinary catheter collection bag was on the seat between the arm of the wheelchair and the resident's leg. The urinary catheter collection bag was not below bladder level to allow drainage of the urine. Certified Nursing Assistant (CNA) Staff T was in the resident's room making the resident's bed and did not place the indwelling catheter bag below the resident's bladder. On 10/20/21 at 2:10 p.m., Resident #19 was observed in bed. The urinary catheter drainage collection bag was observed on the floor. *Photographic Evidence Obtained* Review of the Treatment Administration Record for September 2021 and October 2021 failed to reveal documentation Resident #19 received Foley catheter care on the day shift on 9/19/21 and 9/24/21. The TAR lacked documentation of Foley catheter care on the evening shift on 9/1/21, 9/2/21, 9/5/21, 9/12/21 through 9/14/21, 9/21/21, 9/25/21, 10/3/21, 10/8/21, 10/11/21 and 10/19/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 8 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The TAR lacked documentation of Foley catheter care on the night shift on 9/4/21, 9/5/21, 9/7/21, 9/25/21, 10/2/21,10/3/21, 10/7/21, 10/9/21, 10/11/21 through 10/13/21. On 10/20/21 at 4:18 p.m., in an interview Certified Nursing Assistant (CNA) Staff U said Resident #19 ambulates to and from the bathroom without assistance and will place the Foley catheter drainage bag on the floor. She said when she sees the urinary drainage bag on the floor, she picks it up and attaches it to the side of the bed. The clinical record lacked documentation of interventions to address the concern of Resident #19 placing the urinary catheter drainage bag on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 9 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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** 3. Review of the clinical record for Resident #19 revealed a physician's order dated 6/27/21 for a Foley catheter (Catheter placed in the bladder to drain urine) for urinary retention and Foley catheter care every shift. Review of the care plan for use of indwelling urinary catheter revised on 6/28/21 revealed a goal for no acute complications of urinary catheter use. The interventions included to provide catheter care. Review of the Treatment Administration Record for September 2021 and October 2021 failed to reveal documentation Resident #19 received Foley catheter care on the day shift on 9/19/21 and 9/24/21. The TAR lacked documentation of Foley catheter care on the evening shift on 9/1/21, 9/2/21, 9/5/21, 9/12/21 through 9/14/21, 9/21/21, 9/25/21, 10/3/21, 10/8/21, 10/11/21 and 10/19/21. The TAR lacked documentation of Foley catheter care on the night shift on 9/4/21, 9/5/21, 9/7/21, 9/25/21, 10/2/21,10/3/21, 10/7/21, 10/9/21, 10/11/21 through 10/13/21. Based on clinical record review, review of facility policy, and staff and resident interviews, the facility failed to maintain complete and accurate records for 3 (Residents #14, #19, and #332) of 20 resident records reviewed. Accurate records are necessary to measure progress and facilitate communication among the interdisciplinary team. The findings included: The facility policy Documentation Guidelines (revised 5/21) documented, All treatments ordered/completed are documented on the Treatment Administration Record (TAR) . Don't document before care is provided. 1. On 10/21/21 at 10:30 a.m., in an interview Resident #14 said she had a peripheral inserted central catheter (PICC) (a thin, tube inserted into a vein in the arm or chest used for prolonged intravenous access) that was inserted in her right chest during a recent hospital stay. Resident #14 said the insertion site was covered with a dressing on her right chest and no one at the facility had changed the dressing since she was admitted on [DATE]. Resident #14 said she leaves the facility on Tuesday, Thursday and Saturday for dialysis and had a catheter in the left side of her chest used for the dialysis treatment. The resident said she takes a dialysis communication book containing forms to be completed by the dialysis center to provide information to the staff regarding the services she received at the dialysis center. Resident #14 said, the nurse gives me the dialysis communication book to take with me and then I give it back to them when I come back to the facility. Resident #14 said she was at the dialysis center on 10/19/21 and the dialysis nurse was concerned the dressing on her right chest catheter had not been changed and had a date of 9/18/21 on the dressing. Resident #14 said the dialysis nurse said he was not able to change the dressing for her because it was not part of her dialysis treatment, and a facility nurse would have to change the dressing. Resident #14 said the dialysis nurse wrote a note on the communication form for the facility nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 10 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 to change the dressing. Level of Harm - Minimal harm or potential for actual harm Resident #14 said no one at the facility had changed the dressing to the right chest PICC line until 10/19/21 after the dialysis nurse called the facility. The resident said she was with the dialysis nurse when he called the facility and told the nurse about the dressing. Resident #14 said she gave the nurse the communication book when she returned to the facility and then two nurses came to her room to change the dressing on the right chest PICC line. Residents Affected - Few On 10/21/21 a review of the clinical record for Resident #14 revealed a Hemodialysis Communication Form dated 10/19/19, documented, central line dressing on r/s (right side) was last changed on 9/18/21. The clinical record showed a physician treatment order with a date of 10/6/21 documented, PICC Line change dressing every 72 hours. A review of the TAR for October 2021 showed the treatment was signed by the nurse as completed on 10/9/21, 10/12/21, and 10/15/21. On 10/20/21 at 10:10 a.m., during a telephone interview, the dialysis nurse said he wrote the note for the facility staff on the hemodialysis communication form and highlighted it so they would see it. He said the central catheter dressing on right chest was last changed on 9/18/21 while Resident #14 was in the hospital. He said he was worried about the potential for infection and wanted to alert the facility because the dialysis center had nothing to do with the right-side PICC line and it was up to the facility to address the issue. On 10/21/21 at 11:00 a.m., the interim Director of Nursing (DON) was notified the right PICC line dressing for Resident #14 was reported by dialysis to have a date of 9/18/21 but the TAR showed the dressing change was documented as completed by Registered Nurse (RN) Staff D on 10/9/21, on 10/12/21 documented as completed by Licensed Practical Nurse (LPN) Staff E and on 10/15/21 LPN Staff F documented the treatment was completed. On 10/21/21 at 11:08 a.m., the DON placed a conference call to LPN Staff E, and she declined to answer any questions regarding Resident #14's dressing change or the documentation in the TAR. On 10/21/21 at 11:11 a.m., the DON placed a conference call to LPN Staff F who said the PICC Line was in the right chest and used for IV therapy only and the dialysis line was in the left chest. The LPN confirmed she changed the dressing on the right chest PICC line on 10/15/21. Staff F was notified the dressing on the right chest PICC line was dated 9/18/21 per the dialysis nurse. LPN Staff F said she had signed the dressing change as completed and said, I guess I got busy and forgot to do it. LPN Staff F confirmed it was common practice of the facility to sign for tasks before completing them. LPN Staff F confirmed she did not change the dressing on Resident #14's PICC line. 2. The facility's Documentation Guidelines dated 05/2021 stated, All medications ordered/ administered are documented on the Medication Administration Record. All treatments ordered/ completed are documented on the Treatment Administration Record. Clinical record review showed Resident #332 was admitted to the facility on [DATE] after left hip fracture surgery and discharged to an acute care hospital on 9/20/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 11 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 Resident #332's physician's order summary included a physician's order dated 8/9/21 to float heels (remove all contact between the heel and bed) when in bed, heel protectors when in bed, and to apply betadine (antiseptic solution used to treat or prevent skin and wounds infections) to left heel with deep tissue injury every shift for wound care. Review of the Treatment Administration Record (TAR) for August and September 2021 failed to show documentation the resident's heels were floated, heel protectors applied, and betadine applied on the evening shift of 8/9/21, 8/10/21, 8/12/21, 8/25/21, 8/28/21, 8/30/21, 9/1/21, 9/3/21, 9/4/21, 9/9/21 and 9/17/21. The TAR for August and September 2021 lacked documentation the Resident's heels were floated, heel protectors applied, and betadine applied on the night shift of 8/9/21, 8/11/21, 8/12/21, 8/28/21 and 9/16/21. The TAR for September 2021 lacked documentation the left heel was floated, heel protectors applied, and betadine applied on the day shift of 9/4/21 and 9/10/21. On 10/20/21 at 11:15 a.m., in an interview Registered Nurse (RN) Staff H said the nurse was responsible for documenting the treatments in the TAR. On 10/21/21 at 10:38 a.m., in an interview the Interim Director of Nursing said the ordered treatments should have been done and said, I have no excuse for the poor care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 12 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 Based on observation, review of policies and procedures, and staff and resident interview, the facility failed to provide care and services to minimize the risk of infection of a central line for long term antibiotic use for 1 (Resident #14) of 1 resident reviewed with a central line. The facility failed to maintain appropriate infection prevention measures during pressure ulcer dressing change for 1 (Resident #80) of 2 residents observed for dressing changes. The facility failed to ensure the proper placement of the urinary catheter drainage collection bag to reduce potential complications for 1 (Resident #19) of 1 sampled resident with indwelling catheter. Residents Affected - Few The findings included: 1. Review of facility policy titled, Midline/ Peripherally Inserted Central Catheter (PICC) Dressing Change dated 1/09 stated, the purpose of the dressing is to maintain catheter site integrity by keeping catheter in correct position and covered by an intact dressing; and to reduce the risk of local infection at catheter insertion site and catheter-related bloodstream infection .Change gauze dressing every 48 hours or per physician order. Gauze used under a transparent semi-permeable membrane (TSM) dressing is considered a gauze dressing. Change TSM dressing every 7 days per physician order .Label dressing with date, time, and initials of the person performing the dressing change. Under documentation stated, Record on Medication Administration Record (MAR), Treatment Administration Record (TAR)or progress notes . Review of Resident #14's clinical record showed a readmission to the facility on 9/24/21, after hospitalization for endocarditis (heart infection), with newly placed tunneling central catheter on the right side of chest for antibiotics. The resident's care plan did not reflect care for the right chest central line catheter. The Treatment Administration Record (TAR) for 9/2021 did not include central line dressing change. The Physician's order summary included a verbal order dated 10/6/21 to change the central line dressing every 72 hours. On 10/20/21 at 9:12 a.m., review of Resident #14's dialysis Communication Form to the facility dated 10/19/21 revealed highlighted documentation from dialysis staff that read, central catheter dressing on R/S (right side) was last changed on 9/18/2021. The TAR for 10/2021 had documentation the PICC line dressing was changed on 10/9/21, 10/12/21 and 10/15/21. On 10/20/21 at 10:10 a.m., in a telephone interview the Dialysis Nurse who cared for Resident #14 on 10/19/21 said the central catheter dressing on Resident #14's right chest was last changed on 9/18/21 while she was in the hospital. The Dialysis Nurse said he was worried about the potential for infection and wanted to alert the facility about it. He said the Dialysis Center had nothing to do with the right-side catheter, it was up to the facility to address the issue On 10/21/21 at 11:10 a.m., in an interview Registered Nurse (RN) Staff H said Resident #14 had a left double lumen port for dialysis and the right-side single port for antibiotics. RN Staff H said, Resident had endocarditis if I remember correctly. Dressings are changed weekly or PRN [as needed], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 13 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 we flush before and after meds and each shift. You monitor the dressing and site each shift. dressing changes for central lines are on the TAR is the responsibility of the RN. On 10/21/21 at 10:45 a.m., in an interview Resident #14 showed the surveyor a right chest access site for antibiotics. Resident #14 said the right-side chest dressing had only been changed one time since I came here from the hospital with the one for the antibiotics. They changed it yesterday after he (dialysis nurse) called from the dialysis center and told them to change the dressing. On 10/21/21 at 11:48 a.m., in a conference telephone interview Licensed Practical Nurse (LPN) Staff F said, I remember [Resident #14] had two access sites, the left one for dialysis and the right for antibiotics. LPN Staff F said, I did the dressing on 10/15/21. When asked about the date of 9/18/21 on the dressing, LPN Staff F said, I signed it before I did it and then I got busy, so I guess I forgot. When asked if it was common practice to sign off on tasks before they were completed, LPN Staff F responded, Yes. The Interim Director of Nursing (DON) and Interim Unit Manager Staff Q were present during the telephone interview. On 10/21/21 at 12:25 p.m., in a telephone interview the attending physician said he wasn't aware until 10/6/21 the resident came back with a right chest access site. He said, The nurses never told me she came back with another access. I would expect to be told so the orders can be placed. Of course, we would want the site monitored and kept clean. The physician said the site has been working efficiently without problems, the antibiotics have been administered and the resident has not shown any signs of problem related to the catheter. He said, I don't think there is a reason to become concerned about additional harm. On 10/21/21 at 12:38 p.m., in an interview The DON said, I have no excuse for them not providing the dressing changes or informing the MD [Physician] of the new access. The DON confirmed not having the dressing changed was a quality of care and infection control concern for resident care. 2. The facility's policy and procedure for infection control and clean and aseptic technique, indicates, clean technique refers to practices that reduce the numbers of microorganisms or reduce the risk of transmission from one person or place to another. On 10/20/21 at 2:52 p.m., during observation of wound care treatment and dressing change for Resident #80's coccyx wound, Registered Nurse (RN) Staff P performed the wound care treatment according to doctor's orders but did not follow infection control guidelines for clean and aseptic technique by placing the tube of Santyl (ointment to remove dead tissue) with its bag, directly on the resident bed while she was doing the treatment. RN Staff P then handled the tube and bag with her gloved hands while doing the treatment. The nurse placed the tube of Santyl into its bag and stored it into the clean treatment cart. On 10/20/21 at 2:57 p.m., in an interview with RN Staff P acknowledged she put the prescription bag and Santyl tube on the resident bed while she was doing the treatment and touched the tube of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 14 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 Santyl and bag while doing the treatment. She then placed the potentially contaminated bag and tube back into the clean treatment cart. On 10/20/21 at 3:05 p.m., in an interview with Director of Nursing (DON), he said placing the bag and the Santyl tube on Resident #80's bed while doing the treatment and then placing it back into the treatment cart was not a good infection control practice and should not be done. 3. Review of the facility's ongoing management strategies Indwelling catheters (2012 HCR Healthcare LLC) noted .Strategies to prevent UTI (Urinary Tract Infection) . Keep collection bag below the level of the bladder. Routine meatal care . Review of the clinical record for Resident #19 revealed a physician's order dated 6/27/21 for a Foley catheter (Catheter placed in the bladder to drain urine) for urinary retention and Foley catheter care every shift. Review of the care plan for use of indwelling urinary catheter revised on 6/28/21 revealed a goal for no acute complications of urinary catheter use. The interventions included to provide catheter care and maintain drainage bag below bladder level. On 10/18/21 at 10:45 a.m., Resident #19 was observed in a low bed. The urinary catheter drainage collection bag was on the seat of wheelchair next to the bed above bladder level. *Photographic Evidence Obtained* On 10/19/21 at 9:17 a.m., Resident #19 was observed in bed. The urinary catheter drainage collection bag was on the floor. *Photographic Evidence Obtained* On 10/20/21 at 9:21 a. m., Resident #19 was observed in the wheelchair. The urinary catheter collection bag was on the seat between the arm of the wheelchair and the resident's leg. The urinary catheter collection bag was not below bladder level to allow drainage of the urine. Certified Nursing Assistant (CNA) Staff T was in the resident's room making the resident's bed and did not place the indwelling catheter bag below the resident's bladder. On 10/20/21 at 2:10 p.m., Resident #19 was observed in bed. The urinary catheter drainage collection bag was observed on the floor. *Photographic Evidence Obtained* Review of the Treatment Administration Record for September 2021 and October 2021 failed to reveal documentation Resident #19 received Foley catheter care on the day shift on 9/19/21 and 9/24/21. The TAR lacked documentation of Foley catheter care on the evening shift on 9/1/21, 9/2/21, 9/5/21, 9/12/21 through 9/14/21, 9/21/21, 9/25/21, 10/3/21, 10/8/21, 10/11/21 and 10/19/21. The TAR lacked documentation of Foley catheter care on the night shift on 9/4/21, 9/5/21, 9/7/21, 9/25/21, 10/2/21,10/3/21, 10/7/21, 10/9/21, 10/11/21 through 10/13/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 15 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/20/21 at 4:18 p.m., in an interview Certified Nursing Assistant (CNA) Staff U said Resident #19 ambulates to and from the bathroom without assistance and will place the Foley catheter drainage bag on the floor. She said when she sees the urinary drainage bag on the floor, she picks it up and attaches it to the side of the bed. The clinical record lacked documentation of interventions to address the concern of Resident #19 placing the urinary catheter drainage bag on the floor. Event ID: Facility ID: 105421 If continuation sheet Page 16 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and staff interview the facility failed to maintain a safe and comfortable environment by not making necessary repairs in residents' rooms and bathrooms. Residents Affected - Few The findings included: On 10/18/21 at 4:34 p.m., during observation of Resident #57's bathroom the towel bar was broken and hanging from the wall. *Photographic Evidence Obtained* On 10/19/21 at 8:53 a.m., during observation of Resident 39's bathroom the wall glove holder was missing. There were two holes in the wall next to the mirror where the glove holder had been mounted. The gloves were stored on top of the sharps-container. *Photographic Evidence Obtained* On 10/19/21 at 9:38 a.m., during observation of Resident 284's room there were exposed old telephone wires hanging out of the wall across from Resident #284's bed. *Photographic Evidence Obtained* On 10/21/21 at 1:40 p.m., the Maintenance Director confirmed he was responsible for making repairs throughout the facility, including the residents' rooms and bathrooms. On 10/21/21 at 1:50 p.m., during a facility tour with the Maintenance Director, Resident #57, #39 and #284's rooms were observed. The Maintenance Director confirmed the holes Resident #39's bathroom wall should be repaired, and a new glove holder installed. He confirmed the towel bar in Resident #57's bathroom should be repaired. He confirmed the exposed telephone wires in Resident #284's room should be repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 17 of 18 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 105421 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/21/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodside Health and Rehabilitation Center 3601 Lakewood Blvd Naples, FL 34112 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to demonstrate effective pest control in the rooms of 4 (Resident # 29, #36, #45, and #74) of 4 residents residing in the 400 halls who expressed concerns of bugs in their rooms. Residents Affected - Few The findings included: On 10/18/21 at 12:03 p.m., during interview with Resident #74, small black bugs were observed crawling on the resident's sheets, pillowcases, and the resident's neck. The bugs were also crawling on the outside of the nightstand. The Interim Director of Nursing verified the observation and Resident #74 was relocated to a different room. On 10/21/21 at 3:25 p.m., in an interview Resident #29 and Resident #36 both said there were ants on the windowsill. Resident #29 said, They came along and sprayed yesterday, and the ants aren't there. I tell the nurse when I see them. On 10/21/21 at 3:32 p.m., in an interview Resident #45 stated, I saw a few ants this morning, two or three, and a roach. The resident across the hall throws food out of the window and I have seen possums. On 10/21/21 at 3:45 p.m., in an interview the Interim Director of Nursing said, We have initiated that the Management Department Heads will have a unit and each morning they are to go in the rooms, talking to the residents, looking in the bathrooms for bugs and rodents. Review of the pest control company receipt showed pest activity found on 9/1/21. The report read in part, Lobby, Door-Introduction Point-Open since 9/15/20. Findings. Please note: AC (Air Conditioning) units mounted in the walls of the complex are open to the exterior of the complex. Allowing for Ants to enter the building. Please install filter cover assembly and caulk to seal . The pest control company receipt dated 10/4/21 read in part, Exterior area. Ants noted during service crazy ants and ghost ants. Patient/Guest Rooms-Interior. Ants noted during service crazy ants in room [ROOM NUMBER]. Lobby. Door-Introduction Point-Open since 9/15/20. Please note: AC units mounted in the walls of the complex are open to the exterior of the complex. Allowing for 'Ants' to enter the building. Please install filter cover assembly and caulk to seal. Please address structural concern .? FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105421 If continuation sheet Page 18 of 18