Inspection·December 4, 2020

F 0557 An interview was conducted on 12/04/2020 at 4:11 p.m., the ADON said, It is my expectation that during resident care that the door and privacy curtain if needed are closed to provide privacy for the residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 2 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 Based on observations, interviews and record reviews, the facility failed to perform pressure ulcer care in a manner to promote healing and prevent infection related to not performing dressing changes according to standards of practice and to provide pressure relieving devices for 2 (#5, #20) residents out of 2 sampled for wound care. Residents Affected - Few Findings included: 1.An observation was conducted on 12/01/2020 at approximately 10:48 a.m., Resident #5 was in his room, eyes closed, in bed with a hospital gown on. The resident was positioned on his back. An observation was conducted on 12/03/2020 at approximately 10:18 a.m., Resident #5 was in his room in bed positioned on his back. Review of Resident #5's medical record showed that he was admitted most recently on 8/31/2020 with diagnoses that included Parkinson's Disease. Review of the Wound Care physician's visit report note dated 11/23/2020 showed the following: Focused Wound Exam Site 1: Stage 3 Pressure Wound with a duration of greater than 69 days. Wound size. 2.6 x 1.6 x 0.3 cm; Surface area 4.16 cm; Exudate: Moderate Serosanguineous; Slough 5%; Granulation tissue: This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Dressing Treatment Plan: Primary Dressing (s)Collagen sheet with silver apply once daily for 23 days; Alginate calcium apply once daily for 23 days. Secondary dressing (s) foam silicone border and faced apply once daily for 16 days . Plan of Care reviewed and addressed: Recommendations: Off-loaf wound; Reposition per facility protocol; Low air loss mattress; Multivitamin once daily PO (by mouth); Vitamin C 500 mg twice daily PO. An interview was conducted on 12/03/2020 at 8:45 a.m., the Physician Assistant (PA) stated, If the physician ordered an air mattress then the facility needs to put one on. I am not familiar with Resident #20. You will need to check with her physician. The resident's current physician orders for wound care with an order date of 11/18/2020 and a start date of 11/19/2020 to cleanse the coccyx wound with sterile normal saline (SNS), pat dry, apply collagen sheet with Ag (alginate), calcium alginate, cover with (brand name) dressing once daily. A review of the physician orders and the treatment administration record (TAR) for 11/2020- to 12/02/2020 revealed there was not an order for an air mattress. An order dated 9/01/2020 with out a stop date documented, Restorative nursing to perform bilateral upper extremity active range of motion 2 x 10 reps at all joints and bed mobility with care giver assistance daily 6 x a week. A review of the care plan for Resident #5 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 11/21/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 3 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 Report signs and symptoms of infection to the physician, all with a start date of 11/21/2020. Level of Harm - Minimal harm or potential for actual harm A wound care observation was conducted on 12/03/2020 at approximately 2:00 p.m. Staff D, Registered Nurse (RN) assembled the wound care supplies on top of barrier on a clean bed side table. Staff D and Staff E, Licensed Practical Nurse (LPN), both washed their hands and donned new gloves. Staff E, LPN using the controls located on the foot of the bed raised the resident bed then assisted the resident onto his right side. Staff D, RN picked up the residents catheter and un-hooked it from the side of the bed and put it up on the bed. Staff E said, No this is not an air mattress. Staff D, RN removed the soiled dressing, placed it in a clear bag, removed her gloves, washed her hands, applied new gloves, cleaned the wound four times with SNS solution and a gauze 4x4 cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold and did not change gloves after they were contaminated during the cleaning of the wound. Staff D after completion of the cleaning of the wound, removed her gloves, washed her hands, donned clean gloves, applied the prescribed calcium alginate and covered the wound with a foam bordered dressing. Staff E with his gloves on assisted the resident back on his back and pulled the sheet over the resident. Staff D, RN then picked up the unused supplies/wrappers from the bedside table and put them in the trash. Staff D and Staff E both removed their gloves and washed their hands. Staff D walked out of the resident room and said, I will have to call the physician to get an order for an air mattress. Residents Affected - Few At approximately 2:30 p.m., on 12/03/2020 Staff D, RN was informed of the breaks in infection control that were observed during wound care. Staff D, RN said I understand what you are saying. You clean the wound from the inside out. I should have changed my gloves more often. At approximately 2:40 p.m., on 12/03/2020 the Assistant Director of Nursing (ADON) was informed of the breaks in infection control observed during wound care. She said that the nurses had been trained to do wound care. An interview was conducted on 12/042020 at 9:20 a.m., Staff G, RN said, The beds we purchased have built in mattresses that can be turned into an air mattress, but a tube needs to be connected to it. No, the buttons on the foot of the bed only control the movement of the bed. Something needs to be attached to the bed to make it an air mattress. An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #5's bed last night. I am not sure why there was not one on his bed. There was an order and he was care planned for one. At 17:07 p.m., on 12/04/2020 a copy of the physician orders for Resident #5 was provided by the Nursing Home Administrator (NHA) that revealed an order with a Start Date of 12/03/2020 for Air Mattress for pressure injury. 2. An observation was conducted on 12/03/2020 at 12:25 with Staff D, RN and Staff Resident #20 was in her room in bed lying on her back. The resident's caregiver was sitting at the bedside with a surgical mask on. The caregiver spoke up and said that the resident had just fallen asleep and asked that we come back later to change her dressing. The caregiver said, No she does not have an air mattress on her bed. An interview was conducted on 12/03/2020 at 12:28 p.m., Staff D, RN said, Resident #20's wound was like just a small opening. Then she returned form the hospital and now it is huge. It is on both sides of her coccyx. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 4 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the physician orders revealed an order dated 12/02/2020 for restorative nursing to perform bed mobility and transfers with CGA (care giver assistance) daily 6x/a week. A review of the care plan for Resident #20 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 12/01/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report signs and symptoms of infection to the physician, All with a start date of 12/01/2020. A review of the current wound care orders for Resident #20 was conducted with Staff H, RN, who stated the order was for Santyl ointment 250 unit/gram topical ointment, Treatment Topical apply once daily to bilateral sacrum wound for open area. Cleanse area with Sterile normal saline (SNS), apply Santyl inside wound bed, apply gauze and cover with (brand name) for open area on sacrum. I do not see any wound measurements in the system yet. Maybe she has not been seen by wound care yet. A wound care observation was conducted on 12/04/2020 at 12:46 p.m., Staff H, RN cleaned the bedside table and assembled the wound care supplies and placed them on top of barrier on a clean bed side table. Observed on the foot of the resident's bed was an air mattress pump that was on and connected to the resident's mattress. A caregiver for the resident was sitting in a chair at the foot of the resident's bed. Staff H closed the door to the resident room and pulled the privacy curtain. Staff H, RN washed her hands and donned new gloves. Staff D rolled the resident onto her right side and removed the soiled dressing, placed it in a clear bag and removed her gloves. Staff H confirmed that the resident did not have an air mattress. The resident's coccyx area was red. Staff H removed her gloves and went into the resident bathroom to wash her hands. The caregiver said, I have wondered why she did not have an air mattress before since she has a wound. I guess they put it on her bed last night. Staff H then donned new gloves and cleaned the wound with sterile normal saline solution saturated 4x4 gauze. Staff H cleaned the wound 4 separate times, with clean gauze cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold. Staff D, RN removed her gloves, washed her hands, donned clean gloves, applied the prescribed Santyl ointment and covered the wound with gauze and covered with (brand name). Staff H with her gloves still on positioned the resident back on her back and pulled the sheet up over the resident. Staff H removed her gloves, washed her hands. At approximately 1:10 p.m., on 12/04/2020 Staff H, RN was informed of the breaks in infection control that were observed during wound care. Staff H, RN said You're right, the wound should be cleaned from the inside out. Review of Resident #20's medical record showed that she was admitted most recently on 12/01/2020 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #20's bed last night. I am not sure why there was not one on her bed. There was an order and she is care planned for one. An interview was conducted on 12/04/2020 at 5:37 p.m., the Medical Director said, If the physician ordered the air mattress then the facility should have provided one. An air mattress, it would help off load the pressure of the wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 5 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/03/2020 at 1:59 p.m., the ADON confirmed that neither Resident #5 nor Resident #20's controls located on the foot of the bed for the air mattresses were on. I checked with the IP who went in and checked each of the resident's beds and confirmed neither of them were on. (photographic evidence was obtained). Review of the facility's procedure for Clean Dressing Changes revised 10/30/2019 showed Steps in the Procedure: 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 5. Put on gloves. Adjust bedside stand/table to waist level. Clean bedside stand/table with germicidal disposable cloth. Establish a clean field. 7. Remove gloves and perform hand hygiene. 8. Set up supplies on barrier. 9. Position the resident for comfort. 10. Perform hand hygiene. 11. Put on clean gloves. 12. Remove dressing and place in the resident's trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound with gauze and prescribed cleaning solution using single outward strokes. Use separate gauze for each cleaning wipe. 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene. 21. Reposition the resident and ensure the call light is in place. 22. Discard all disposable items into the appropriate receptacle. 23. Clean the bedside stand/table with germicidal disposable cloth. 24. Remove trash can from resident's room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 6 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 25. Wash and dry hands thoroughly . Level of Harm - Minimal harm or potential for actual harm A review of the facility policy and procedure titled Infection Control-Hand Hygiene with a reviewed date of 10/30/2020 revealed: #3. The Centers for Medicare and Medicaid service operations manual indicates that hand hygiene should be performed: Residents Affected - Few a. When coming on duty; b. Before and after performing any invasive procedure (e.g., finger stick blood sampling); c. Before and after entering isolation precautions settings; . d. Before and after assisting a resident with meals; e. Before and after assisting a resident with personal care; f. Before and after handling peripheral vascular catheters and other invasive devices; . g. Before and after inserting indwelling catheter; h. Before and after changing a dressing i. Upon and after coming in contact with the resident's intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident); j. Before and after assisting a resident with toileting; k. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 7 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 After blowing or wiping nose; Level of Harm - Minimal harm or potential for actual harm l. After contact with resident's mucous membranes and body fluids or excretions; Residents Affected - Few m. After handling soiled or used linens, dressing, bed pants, catheters , an urinals semi colons after handling soiled equipment or utensils; n. After removing gloves or aprons; o. After completing duty. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 8 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 interview the facility failed to 1) ensure that oxygen was administered according to the physician orders for one (43) of 3 sampled residents and 2) failed to ensure respiratory equipment used for inhalation therapy was maintained in a clean and sanitary manner for 4 (12/01/2020, 12/02/2020, 12/03/2020, 12/04/2020) out of 4 days for 1 (#42) resident out of 3 residents with inhalation therapy observed. Residents Affected - Few Findings included: 1. Observations on 12/1/20 at 11:01 AM of Resident #43's room revealed that the residents oxygen tubing was noted to be wrapped around the oxygen concentrator . Closer observations revealed that the oxygen tubing was unlabeled and un-bagged. Observations of the residents room on 12/1/20 at 1:28 PM revealed that the oxygen nasal [NAME] was attached to the oxygen concentrator with the excess oxygen tubing noted to be on the floor. It was noted that the oxygen tubing was unlabeled and un-bagged. Closer observation of the oxygen concentrator at this time revealed that the oxygen concentrator was set at 4 liters. Observation of resident #43 on 12/3/20 at 11:50 AM revealed that the resident was receiving oxygen from his oxygen concentrator which was observed to be set between 4.5 and 5. liters. Interview with the resident at this time revealed that he received continuous oxygen and that staff set up his concentrator. He reported that if he leaves his room then he uses the oxygen tank which staff also set up for him. At this time the excess oxygen tubing was noted to be lying on the floor. (Photographic evidence obtained) Review of the residence record revealed that the resident had a current physicians order for O2 at 3 LPM via NC Continuous every shift. Review of the residents care plan revealed that the interventions indicated the resident was to receive 2 liters of oxygen per minute. Observation of resident number #43 on 12/3/20 at 12:00 PM revealed that the resident was sitting in his room and he was receiving oxygen from his oxygen concentrator. Closer observations of the oxygen concentrator revealed that it was set between 4.5 and 5.0 liters per minute. Interview on 12/3/20 at 12:03 PM with the Assistant Director of Nursing (ADON) after reviewing the residents physician order revealed that the resident was to receive oxygen at 3 liters per minute. Interview on 12/3/20 at 12:05 PM with Staff A, RN revealed that the resident was to receive 3 liters of oxygen. Observations on 12/3/20 at 12:07 PM of the residents oxygen concentrator while in use by the resident with Staff A, RN and the ADON present in the room, the ADON inspected the oxygen concentrator and reported that the oxygen concentrator was running at almost 5 Liters She reported that it would be checked and changed to reflect the current physician orders. Interview on 12/3/20 at 12:10 PM with Staff A, RN revealed that the resident is on continues (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 9 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen, and that she has worked with the resident for the past 2 days. She reported that the resident uses his oxygen tank when he is out of his room and that she checks the residents oxygen tank when he changes to it, but that she has not checked his concentrator. She stated that it is to be checked at least each shift. Interview on 12/3/20 at 12:11 PM with the ADON revealed that the expectation for the provision of oxygen is that the nurses are to follow physicians orders. Interview on 12/3/20 at 12:33 PM with the MDS Coordinator revealed that the care plan is based on physician orders and that the current care plan indicates 2 Liters. At this time the MDS Coordinator reviewed the resident's current physician orders and confirmed that the resident is currently on 3 Liters of oxygen and reported that she will update the residents care plan now to reflect his current order. 2. An observation was conducted on 12/01/2020 at 11:16 a.m., Resident #42 was in her room in bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). The resident said, That is where the nurse's put it after they are done. An interview was conducted on 12/01/2020 at 2:48 p.m., The Infection Preventionist (IP) who said, Neb/pipes and respiratory equipment used for inhalation therapy, the nurses are supposed to clean them after use and put them in a plastic bag. The bags are supposed to be changed weekly. A review of the medical record for Resident #42 revealed a recent admission date of 11/21/2019 with a pertinent diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The physician orders revealed a current order dated 10/19/2020 for Albuterol sulfate 0.63% mg/3 ml solution for nebulization vial inhalation as needed every 4 hours for shortness of breath. An observation was conducted on 12/02/2020 at approximately 11:30 a.m., Resident #42 was in her room up in her wheelchair. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An observation was conducted on 12/03/2020 at approximately 8:40 a.m., Resident #42 was in bed with her oxygen on. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 8:33 a.m., with Staff H, Registered Nurse (RN) who said, After the resident completes a respiratory treatment the nurses are supposed to clean out the equipment, dry it off and put it back in the plastic bag that should be kept at the bedside. An observation was conducted on 12/04/2020 at approximately 12:50 p.m., Resident #42 was up in her wheelchair sitting next to her bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 5:28 p.m., The ADON said, All nebulizer and oxygen equipment is to be stored in a bag. I am not sure when the last time it was used but it should not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 10 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0695 matter. We have a company that comes in and takes care of our respiratory equipment. Level of Harm - Minimal harm or potential for actual harm A review of the facility policy titled Infection Control-Cleaning and Disinfection/Non-Critical care and shared equipment last reviewed on 10/30/2019 revealed, Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations and National guidelines. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 11 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not accommodate dietary preferences and intolerances for one (Resident #40) out of five sampled residents. Findings included: Resident #40 was admitted to the facility with a diagnoses that included pneumonia unspecified, Dysphagia, Gastro-esophageal reflux and chronic kidney disease. A review of Resident #40's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 signifying moderately impaired cognition. Section K on Swallowing and nutritional status showed diet orders of Regular diet, Lactose free. On 12/03/20 at 8:30 a.m., Resident #40 was observed in her room eating breakfast, her cereal bowl was full however she was not eating the cereal. Resident #40 stated, they gave me the wrong milk. I don't drink that. A regular milk carton was observed on her tray. On 12/03/20 at 12:18 p.m., another observation was made of Resident #40 being assisted with her meal by Staff C, Certified Nurse's Aide (CNA). Staff C, CNA told resident #40 that she did not receive milk with her tray. A review of Resident #40's meal ticket dated 12/03/20 revealed the following statement, sorry, out of lactose milk, waiting on delivery. The meal ticket also confirmed that Resident #40's diet included a lactose free diet. A review of physician's orders with a print date of 12/03/20 under Allergies confirmed that resident #40 was Lactose intolerant. Resident #40's Care Plan dated 07/23/19 under nutrition showed a goal to maintain nutritional status at optimal level possible with an approach to honor food preferences as applicable. The plan further confirmed a lactose free diet was ordered. A review of the dietary pre-interview screen dated, 11/25/19 under food allergies confirmed that Resident #40 was lactose intolerant. On 12/03/20 9:32 a.m., an interview was conducted with the Registered Dietician (RD). She confirmed that the resident was lactose intolerant and should not have been served regular milk. An interview with the Minimum Data Set (MDS) Coordinator conducted on 12/03/20 at 09:59 a.m. also confirmed that Resident # 40 should be served a lactose free diet. A follow-up interview was conducted on 12/03/20 at 12:12 p.m. with the Certified Dietary Manager (CDM). CDM reported that the truck delivery arrived this morning and the lactose milk was back ordered. When asked if there was a plan to meet the resident's needs in circumstances like those, CDM stated that they would go to the grocery store and get a gallon of milk. On 12/04/20 12:37 p.m. another interview was conducted with the RD who reported that Resident # 40 was not served lactose free milk this morning again because the truck still had not come. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 12 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0806 A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide each resident a nourishing diet that meets special dietary needs including preferences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 13 of 14 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 105660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manor at Carpenters, The 1001 Carpenters Way Lakeland, FL 33809 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. 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 reviews, the facility did not provide assistive devices to ordered maintain independence during meals for one (Resident #40) out of five sampled residents. Residents Affected - Few Findings included: Resident #40 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia and muscle weakness. A review of Resident #40's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment. A review of Resident # 40's Care Plan with a start date of 7/23/19 revealed a nutritional risk related to certification of terminal illness, therapeutic diet, and a history of weight loss. The goal is noted to maintain nutritional status at most optimal levels. Approach number 12 states to offer a lipped plate. During an initial tour of hallway 112-128 on 12/01/20 at 9:50 a.m., an observation was made of resident #40 in her room eating breakfast, served in a regular plate. Her meal plate was noted to be full. On a subsequent visit on 12/01/20 at 11:14 a.m., Resident #40 was observed sitting in bed, breakfast tray in front of her and the meal not touched. An interview with the resident revealed that Resident #40 did not know if she needed assistance with meals or what specialized equipment was prescribed in her care plan. On 12/02/20 08:49 a.m., Resident #40 was observed sitting in bed, eating breakfast without a lipped plate and with regular silverware, photographic evidence obtained. On 12/03/20 at 09:32 a.m., an interview was conducted with the Registered Dietician (RD) who confirmed that Resident #40 should have been served with a lipped plate and that a lipped plate was ordered for all meals. A follow-up interview was conducted with the Rehabilitation Director on 12/03/20 at 09:39 a.m. who stated that the lipped plate was ordered on every meal effective 10/16/20 for Resident #40. On 12/03/20 at 09:59 a.m., an interview with the Minimum Data Set (MDS) Coordinator was conducted. MDS stated that Resident #40 should have a lipped plate all the time. A review of Resident's 40's meal ticket order dated, 12/03/20 under equipment showed to provide a lipped plate. A review of the physician's order provided by the Rehabilitation Director confirmed that Resident #40 is to be provided a lipped plate with all meals. A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide special eating equipment and utensils for residents who need them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 14 of 14