Inspection·February 11, 2022

F 0684 Level of Harm - Minimal harm or potential for actual harm On 02/10/22 at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had MRSA in the urine and a UTI. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. Residents Affected - Few On 02/11/22 at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. They had a physician notebook the nurses use to write any symptoms or problems the residents are having. The ICP reported she looks through the book daily and looks at new orders every morning. She gets with the physician if the resident was symptomatic to order a UA and she was responsible for checking the results of the labs. She reported the turnaround time was not good for receiving UA results and it could take anywhere from 2-4 days. The UA for Resident #39 was ordered on 02/02. The results were received 02/05/22 per the labs, but she could not promise 02/05 was the date the facility received the results. After further review of Resident #39's electronic medical record, the Infection Preventionist stated they received the results on 02/07 at 11:21 in the a.m. She stated the doctor was called, and he said to put it in the book for tomorrow and the next morning he would write the orders. She confirmed they could call the labs for results. She confirmed the antibiotics for Resident #39 were started on the 8th. She stated a week was too long for waiting for lab results. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She agreed one week was a long time to wait before a resident gets treatment. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICP reported the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. The policy provided by the facility titled, Diagnostic Services, dated 10/22/20 revealed the following: Intent: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Procedure: 1. The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 2 of 12 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 02/11/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days for one (Resident #33) of seven residents investigated for unnecessary medications. Findings included: On 2/08/22 at 12:18 p.m. Resident #33 was observed lying in his bed fully dressed. A personal caregiver was present in the room. The resident appeared clean, dry and had no odors. The resident was unable to answer questions about his care and he appeared calm and cooperative. A review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including: cognitive impairment, dementia, anxiety disorder, and mood disorder. A review of the Physician's Order set, dated 2/11/22, revealed an active order for Ativan 0.25 milligrams (mg) one by mouth every 6 hours as needed for anxiety started 11/2/21 with no stop date (last dose 12/8/21). A review of the comprehensive care plan for Resident #33 revealed the following focus area: Psychotropic drugs: [Resident #33] is on psychotropics due to depression, anxiety, and insomnia (start date 10/15/21). Goal: Will be free of depressive/anxious//insomnia behaviors and adverse effects of medication through the review date (goal date 5/9/22). Interventions included: Monitor and document all behaviors related to depression/anxiety/hypnotic such as episodes of tearfulness, withdrawal from friends/family. Monitor and document side effects of antidepressant, hypnotic, and antianxiety medications. Monitor for lowest possible dose. A review of the Medication Records from 12/2021 through 2/10/2022 revealed no documented behaviors for anxiety and only one dose of Ativan given on 12/8/2021. A review of the Medication Regimen Reviews (MRR) conducted by the Consulting Pharmacist (CP) indicated on 10/23/2021 a recommendation was sent to the physician to evaluate the resident for the appropriateness of Ativan 0.25 mg every 6 hours as needed. There was no response documented on the recommendation from the provider. On 2/11/22 at 11:10 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the policy is not to have PRN medications for more than 14 days for psychotropic medications. She stated they review all residents on these medications monthly in their psychiatric meetings. She stated the CP and nursing, all review residents for any gradual dose reductions to identify changes that need to be made. On 2/11/22 at 11:13 a.m. a telephone interview was conducted with the Consulting Pharmacist. She stated she had sent a recommendation on October 23rd, after her MRR for Resident #33 to address the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 3 of 12 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 02/11/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few PRN status of the Ativan. She stated she did not see that a change on the medication had been made. She stated she did prepare notes for the January meeting related to Resident #33. She stated another member of the pharmacy attended the meeting, so she was not aware of the outcome. She stated PRN psychotropics are something she would let the provider know about and the medications should not be continued without further explanations. She stated she would recommend if needed the medication be changed to a routine medication. A review of the policy titled, Pharmacy Services-Drug Regimen Free From Unnecessary Drugs, updated on 10/22/20, indicated the following: Intent: the intent of this policy is each resident's entire drug/medication regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medications; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 1 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: a. In excessive dose b. For excessive duration c. Without adequate monitoring d. Without adequate indications for its use e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued f. Any combinations of the reasons stated 2 A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety d. Hypnotic 3. Based on a comprehensive assessment of a resident, the facility will ensure that: c. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 4 of 12 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 02/11/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm d. PRN orders for psychotropic drugs are limited to 14 days. Except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 5 of 12 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 02/11/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, record review, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Residents Affected - Some Findings included: On 02/08/22 starting at 10:00 a.m., an initial tour of the kitchen was conducted with the Director of Dining and the chef. Rust was observed on the ceiling tiles in the dishwashing area. The Director of Dining stated they were in the process of remodeling, and it should take place within the next six months. There were two male staff members running dishes through the dish machine. One of the male staff members had an excessive amount of facial hair sticking out from around his surgical mask. He was not wearing a beard guard. Three gallons of expired milk dated 01/28, 02/02, and 02/05 was observed in walk in cooler number one. The following was observed in walked in cooler number two: *a case of raw thawed ground pork stored on the shelf above a case of fully cooked meatballs; *a case of raw thawed tenderloin stored on the shelf above a case of fully cooked meatballs; and *black buildup was observed on the ceiling and on the fan in the back of the walk-in cooler. A staff member was observed touching the trash can lid with her hand to throw trash away and then put the oven mitt on her hand with no hand hygiene until the Director of Dining interfered. On 02/10/22 starting at 10:37 a.m., a follow up tour of the kitchen was conducted. A personal phone was observed on the food prep table. The Director of Dining removed the phone after the surveyor asked who did the phone belong to. On 02/10/22 at 10:45 a.m., the Director of Dining confirmed the male staff member should have been wearing a beard guard. He stated the truck came on the day the expired milk was observed in the walk-in cooler and the person responsible for ensuring there were no expired foods in the walk-in cooler did not get to pull it out. He stated they receive deliveries almost daily. The Director of Dining stated the food code indicated that raw foods could be stored over ready to eat foods and they use the food code for their policy. He reported that maintenance replaced the rusty tiles and cleaned the fan in the walk-in cooler yesterday and maintenance would have to use a sand blaster to clean the ceiling. On 02/10/22 at 12:40 p.m., the Director of Dining stated they use the food code for all their policies. An online form had to be submitted for maintenance requests to submit work orders, but maintenance comes around 30-45 days to check for maintenance issues. Hand hygiene should be performed anytime you go from dirty to clean or changing tasks. They have hand washing signs posted throughout the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 6 of 12 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 02/11/2022 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 0812 facility. No personal items can be in the food preparation area. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 7 of 12 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 02/11/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of intracardiac thrombosis, diabetes mellitus, Parkinson's Disease, and peripheral vascular disease. The Physician's Order set dated [DATE] indicated an active order for wound care, with a start date of [DATE], as: cleanse wound on sacrum with normal saline, pat dry, apply Hydrofera Blue to wound bed, cover with Allevyn dressing daily. Residents Affected - Few A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, under Section M--Skin Conditions, Resident #4 had a Stage 4 pressure ulcer, not present on admission. A review of the Comprehensive Care Plan for Resident #4 indicated the following focus area started on [DATE]: Pressure Ulcers: [Resident #4] has potential for impaired skin integrity, at risk due to weakness, dementia, Parkinson's. Goal: Will prevent resident from developing a pressure ulcer unless resident's clinical condition demonstrates that they were unavoidable. Skin will be kept as clean and dry as possible on a daily basis. Interventions included: obtain physician order for treatment and use of pressure relieving devices as indicated; treatment as ordered, cleansing, application of medications, packing and/or dressings change with wound status and progress. A review of the wound care notes revealed the following measurements: Stage 4 Coccyx date opened [DATE], [DATE]--2.7 x 0.5 x 0.4, [DATE]--3.0 x 0.6 x 0.4, [DATE]--4.0 x 0.9 x 0.2, [DATE]--7.5 x 4.0 x 0.2. On [DATE] at 10:49 a.m. Resident #4 was observed lying in his bed. The resident was friendly and appeared confused. Staff A, Registered Nurse (RN), Unit Manager and Staff B, Certified Nursing Assistant (CNA), were preparing to do wound care for the resident. The resident had been previously medicated and had been informed about the procedure. Resident #4 was confused and making jokes during the procedure. The nurse stated the resident has had the wound for a while and the wound care physician comes once a week to assess and measure the wound. The nurse stated the physician does all the measurements and provides any changes in orders as needed. Staff A, RN cleaned the overbed table with bleach wipes and let the table dry over two minutes. A drape was placed on the table. Both staff members cleaned their hands and put on gloves. Supplies for the procedure were placed on the table by the RN. The resident was prepared for the procedure by the CNA. The RN stated the dressing was already removed during care by a CNA due to soilage. The RN proceeded to examine the wound with her gloved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 8 of 12 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 02/11/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hands and expose the area to be cleansed. The nurse removed her gloves, cleansed her hands, and put on a new pair of gloves. Staff A, RN then cleaned the wound with normal saline and four by four sponges from inside of the wound to the outside of the wound using five wiping motions. No hand hygiene or change of gloves was noted after the dirty wound was cleaned. The nurse then applied skin prep to the peri wound area. The nurse then applied the Hydrofera Blue to the inside of the wound. The nurse then applied the Allevyn dressing over the wound and secured it to the skin. The nurse then assisted to reposition the resident and replace the brief. No hand hygiene or change of gloves was noted prior to repositioning the resident after the procedure. The nurse removed her gloves, washed her hands, and placed a new pair of gloves on. The nurse then disposed of the garbage and cleaned the scissors and the table tray with bleach wipes. The nurse then removed her gloves, washed her hands, and left the room. An interview was conducted with Staff A, RN immediately after the wound care observation. The nurse confirmed she had not changed her gloves and washed her hands in between the cleaning of the wound and the application of the new dressing. The nurse stated she should have done so. A review of the policy titled, Clean Dressing Change, date last reviewed: [DATE] revealed the following: Intent: It is the policy of the facility to ensure change dressings in accordance with State and Federal Regulations, and national guidelines. Procedure: 11. Put on clean gloves 12. Remove dressings and place in the resident' 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 stokes. Use separate gauze for each cleansings 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 9 of 12 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 02/11/2022 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 0880 24. Remove trash from resident' room Level of Harm - Minimal harm or potential for actual harm 25. Wash and dry hands thoroughly 26. Document the completion of dressing change on the treatment record. Residents Affected - Few On [DATE] at 10:38 a.m. an interview was conducted with the Director of Nursing (DON). She stated the nurse needed to wash her hands and change her gloves after cleaning the dirty wound and before placing the dressings. On [DATE] at 10:51 a.m. an interview was conducted with the Infection Control Preventionist. She stated she was informed about the error that occurred during wound care and confirmed hand hygiene and glove change should be performed after cleaning the dirty wound and before the nurse placed the clean dressings. Based on observations, record reviews, and interviews, the facility failed to ensure isolation precautions were initiated in a timely manner for one resident (Resident #39) and failed to ensure appropriate hand hygiene was performed during wound care for one resident (Resident #4) out of the sampled three residents. Findings included: 1. A review of the Profile Face Sheet revealed Resident #39's diagnoses included but was not limited to benign prostatic hyperplasia without lower urinary tract. A review of the Physician's Orders for [DATE] revealed the following order: Urinalysis Culture and Sensitivity (UA C&S) with a start date of [DATE]. A review of the lab results, dated [DATE], revealed a collection date and an order date of [DATE]. The urine culture revealed Resident #39 had Methicillin-Resistant Staphylococcus Aureus (MRSA). The urinalysis showed the blood, protein, nitrite, and leukocytes were abnormal. The microscopic urinalysis showed the white blood cells, red blood cells, and bacteria were abnormal. A review of the Physician's Orders for [DATE] revealed the following order: Linezolid 600 mg (milligram) tablet by mouth every 12 hours for UTI (urinary tract infection) for 7 days with a start date of [DATE] and a stop date of [DATE]. There was no physician order related to isolation. The Medication Record for 02/2022 reflected the Linezolid was administered as ordered starting on [DATE]. The care plan related to infections revealed a category for UTI initiated on [DATE]. The approaches included but were not limited to apply infection control precautions and procedures as needed. Several observations on [DATE] and [DATE] revealed a caddy with personal protective equipment (PPE) was not on or outside of Resident #39's room door. There was no signage that indicated staff had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 10 of 12 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 02/11/2022 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 0880 wear PPE when providing care. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had MRSA in the urine and a UTI. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. Residents Affected - Few On [DATE] at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. The UA for Resident #39 was ordered on 02/02. The results were received [DATE] per the labs, but she could not promise 02/05 was the date the facility received the results. After further review of Resident #39's electronic medical record, the ICP stated they received the results on 02/07 at 11:21 in the a.m. She confirmed the antibiotics were started on the 8th. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICPreported she did not know when the caddy was put on the door. Normally the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. On [DATE] at 11:30 a.m., a policy related to isolation for MRSA was requested and not provided. A review of the Centers for Disease Control and Prevention document titled, Methicillin-Resistant Staphylococcus Aureus (MRSA) General Information Patient found at https://www.cdc.gov/mrsa/community/patients.html revealed: To prevent MRSA infections, healthcare personnel: Clean their hands with soap and water or an alcohol-based hand sanitizer before and after caring for every patient. Carefully clean hospital rooms and medical equipment. Use Contact Precautions when caring for patients with MRSA (colonized, or carrying, and infected). Contact Precautions mean: o Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 11 of 12 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 02/11/2022 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 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for one staff member (D) of three sampled staff members for COVID-19 testing. Residents Affected - Few Findings included: An interview was conducted on 02/11/2022 at 11:24 a.m. with the facility's Infection Control Preventionist (ICP) and Nursing Home Administrator (NHA). The ICP confirmed the facility was in outbreak status that started on 12/11/21 and the last positive result for a resident was on 2/1/22 and for a staff member was 2/3/22. The ICP stated all staff in the facility were tested on ce weekly, and the NHA stated testing frequency was based off of the current guidelines. A request was made on 02/11/2022 at 12:02 p.m. for review of Staff D, Dietary's previous three COVID-19 testing results from the NHA. A review of Staff D, Dietary's COVID-19 testing results, dated 01/14/2022, revealed Staff D, Dietary tested negative for COVID-19. No other COVID-19 test results for Staff D, Dietary were provided by the NHA. An interview was conducted on 02/11/2022 at 12:21 p.m. with the NHA. The NHA stated Staff D, Dietary was recently hired on 01/07/2022 and addressed there was only one COVID-19 test result available. The NHA also stated he would check to see when the last time Staff D, Dietary worked and would follow up to see if any other results were available. A follow up interview was conducted on 02/11/2022 at 1:01 p.m. with the NHA. The NHA stated Staff D, Dietary last worked in the facility on 02/10/2022 and no other COVID-19 testing results were able to be found for Staff D, Dietary. A review of the facility policy titled, Testing Policy for COVID-19, last revised 05/21/2021, revealed under the section titled Staff Testing that staff members of the facility will be tested according to regulatory guidance. If a staff member is unable or unwilling to be tested, the individual will be removed from the schedule until test results can be provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 12 of 12