Health inspection·January 18, 2024

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the care plan for Resident #40 did not identify a focus related to self administration of the pain patch by Resident #40. The policy - Self-Administration of Medication Program, reviewed on 11/22/23, revealed it is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate. A continued review of the policy showed: - 4. If a resident requests to self-administer drugs, it is the responsibility of the Interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer drugs, before the resident may exercise that right. - 5n. The resident's ability to ensure that medication is stored safely and securely. - 6. Once the resident has been deemed safe by the IDT an order will be obtained from the resident's physician or physician or physician extender listing the medication(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration. - 10. The decision that a resident has the ability to self-administer medication(s) is subject to periodic re-evaluation based on change in the resident's status. - 11. The resident will be re-evaluated on their ability to continue to self-administer medications in conjunction with the resident assessment instrument. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 2 of 6 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 01/18/2024 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to confirm the accuracy of the Pre-admission Screening and Resident Review (PASRR) and to correct the document for five (#3, #13, #40, #41, and #207) out of twenty-one residents sampled. Residents Affected - Few Findings included: 1. Review of Resident #3's admission Record revealed the resident was admitted on [DATE]. The record included the resident diagnosis of unspecified single episode of major depressive disorder with onset dates of 1/19/20, 5/18/20, 6/19/20, 10/16/20, and 10/10/22, and unspecified anxiety disorder with an onset date of 1/19/20. Review of Resident #3's PASRR, dated 5/18/20, did not reveal the resident had a Mental Illness (MI), a suspected MI, or an Intellectual Disability (ID). The PASRR showed the resident did not require a Level II PASRR screening. 2. Review of Resident #13's admission Record revealed the resident was admitted on [DATE]. The record revealed the resident's primary diagnosis on 12/5/18 was unspecified Cerebral Palsy and included the diagnoses of unspecified single episode major depressive disorder and unspecified anxiety disorder dated 11/27/18. The record revealed the diagnosis of Cerebral Palsy was recognized on 11/6/20 and 1/9/21 and the diagnoses of major depressive and anxiety disorders were documented on 11/27/18, 11/6/20, and 1/9/21. A review of Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The resident's PASRR showed the resident did not require a Level II PASRR evaluation. 3. Review of Resident #40's admission Record revealed the resident was admitted on [DATE]. The record included diagnosis of moderate recurrent major depressive disorder with an onset date of 12/7/21. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #40 had a diagnosis of non-Alzheimer's dementia. A review of Resident #40's PASRR completed at an acute care facility on 12/7/21 showed the resident did not have a MI, suspected MI, or ID and did not require a Level II PASRR evaluation. 4. Review of the admission Record showed Resident #41 was admitted on [DATE] and readmitted on [DATE] with a diagnosis of Major Depressive Disorder, and other co-morbidities. Review of Resident #41's PASRR Level I Assessment, dated 07/25/2022 did not reveal a qualifying mental health diagnosis marked in section I A. Resident #41 was readmitted on [DATE] with a new diagnosis of Major Depressive Disorder. 5. Review of the admission Record showed Resident #207 was admitted on [DATE] with diagnoses of psychotic disorder, Alzheimer's Disease, Dementia with behavioral disturbance, mood disorder, and other co-morbidities. Review of Resident #207's PASRR Level I Assessment, dated 01/02/2024 did not reveal a qualifying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 3 of 6 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 01/18/2024 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 0645 Level of Harm - Minimal harm or potential for actual harm mental health diagnosis marked in section I A. and had a primary diagnosis of dementia. Section II, (7) was marked yes for having validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). During an interview on 01/17/24 at 01:59 PM, the Social Service Director (SSD) confirmed: Residents Affected - Few Resident #3's PASRR does not reflect the diagnosis for MDD. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #40's PASRR dated 12/07/21 did not show the resident had a MI, suspected MI, or ID and did not require a Level II PASRR evaluation. The SSD confirmed the diagnoses should be on the PASRR. This PASRR needs to be accurately completed and submitted for a Level II screening. Resident #41 was readmitted on [DATE]. A new PASRR was not completed. The SSD confirmed that a new PASRR would need to be completed to include the new diagnosis of Major Depressive Disorder and resubmitted for a Level II screening. The SSD confirmed Resident #207's PASRR is incorrect and needs to be redone and submitted for a Level II screening. Review of the facilities policy and procedures titled Coordination - Pre-admission Screening and Resident Review (PASRR) program, with a last review date of 11/22/2023 showed: Intent: it is the policy of the facility to assure that all residents admitted to the facility receive a PASRR, in accordance with the State and Federal regulations. Procedures: . 2. b. Referring all Level II residents and all residents with newly evident or possible serious mental disorders, intellectual disabilities, or related condition for Level II resident review upon a significant change in status assessment. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for resident review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 4 of 6 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 01/18/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to assess and obtain physician orders for the two wounds for one (#40) out of four resident sampled for skin conditions. Residents Affected - Few Findings included: An observation was made on 1/16/24 at 10:35 a.m., of an undated large brown-colored adhesive bandage, applied to Resident #40's left wrist and a white 3x3 centimeter (cm) bordered dressing dated 1/15 on the outer aspect of the resident's right leg. During the observation on 1/16/24 at 10:35 a.m. Resident #40 stated (regarding left wrist) it happened a week ago, scraped it, and skin was hanging. The Resident stated the Band-Aid was changed over the weekend. An observation and interview was conducted on 1/17/24 at 2:24 p.m. with Resident #40. A white bordered dressing dated 1/15/24 continued to be observed on the resident's right lower leg. The resident reported rubbing the leg against the over bed table (pointing at it) last week. A large brown-colored undated adhesive dressing had been applied to the resident's left wrist. The resident reported tripping into the dresser and the nurse had applied the adhesive dressing this weekend. An interview and observation was conducted on 1/17/24 at 2:28 p.m. with Staff A, Registered Nurse (RN). The staff member stated Resident #40 did not have any skin conditions. The staff member stated if there was a dressing on the resident's lower leg it had not been applied by him. Staff A observed the white dressing on Resident #40's right lower extremity (RLE), confirming it was dated 1/15/24 and the adhesive dressing on right wrist. The resident reported to the staff member of scrapping it (leg) on the over bed table. Immediately following the observation, Staff A reviewed the electronic record of the resident and confirmed there was no report or treatment order for either injury. On 1/17/24 at 5:05 p.m., during an interview, the Infection Preventionist (IP) reported observing the skin tears of Resident #40 and both areas were old. The IP reported both areas should have had orders for treatments. A review of the facility report log dated 11/11/23 to 1/16/24 did not reveal Resident #40 had suffered any injury. Review of Resident #40's physician orders included an order for Weekly skin assessment to be completed in [electronic record] on Sunday 3-11 shift every week, to start on 6/8/23. A review on 1/17/24 at 1:45 p.m., revealed the last Interdisciplinary (ID) nursing note written on 9/5/23 was regarding the request by the Resident #40's Power of Attorney to discontinue the fentanyl patch. The ID notes did not include any information regarding the left wrist or right leg injury suffered by the resident. Review of Resident #40's January 2024 Treatment Administration Record (TAR) revealed no wound care orders until 1/17/24 and wound care had not been provided to the resident's right lower extremity or left wrist. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 5 of 6 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 01/18/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the Skin Evaluations revealed a skin assessment had last been completed on 12/24/23 on Resident #40. The facility did not provide any further weekly skin evaluations for 12/31/23, 1/7/24, and 1/14/24. On 1/17/24 at 2:50 p.m., during an interview, the Director of Nursing stated if it (an incident) happens during the day, wound care can see it, if not staff are to notify the physician and obtain any order for treatment. She stated if is a skin tear or pressure injury an incident report is required. The DON stated usually there was a nursing note generated in the incident report. She reviewed and confirmed there were no treatment orders for either skin injury. A policy titled - Charting and Documentation, undated, revealed All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy showed: - All observations, medications administered, services performed, etcera (etc), must be documented in the resident's clinical record. - All incidents, accidents, or changes in the resident's condition must be recorded. A policy titled - Wound Prevention, reviewed 11/23/21, revealed the purpose was to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. The process showed Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). The policy titled - Change in Condition Process, reviewed 11/23/21, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 6 of 6