Health inspection·March 17, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interview, personnel record review, and review of facility policies and procedures, the facility did not ensure abuse policies and procedures related to screening of potential employees were followed. The facility did not attempt to obtain information from previous or current employers for one staff member (Staff A, Certified Nursing Assistant) out of five staff members reviewed, resulting in harm to Resident #1. Residents Affected - Few Findings included: Review of the record for Resident #1 revealed she was admitted to the facility on [DATE]. Diagnoses included depression, senile degeneration of the brain, cerebral atherosclerosis, major depressive disorder, and dementia without behaviors. Review of a quarterly Minimum Data Set (MDS) assessment completed 12/13/24 revealed Resident #1 was rarely/never understood and was dependent on staff for upper body dressing, oral care, toileting, bathing, personal hygiene, and lower body dressing. The assessment revealed Resident #1 was dependent on staff for transfers. Review of a facility report dated 3/12/25 indicated Staff A, Certified Nursing Assistant (CNA) physically abused Resident #1 on 3/12/25 when Resident #1 became combative during care. An interview was conducted with the Administrator at 1:35 p.m. on 3/17/25. The Administrator stated she found out from other staff while conducting the investigation involving Resident #1, Staff A, CNA, was fired from another nursing facility recently for abusing a resident. The Administrator stated Staff A, CNA, told them it was her first job as a CNA. Review of the personnel record for Staff A, CNA revealed she completed an employment application on 2/24/25 where she listed her previous employment at two fast food restaurants and both fast food restaurants were contacted by human resources for references. Review of a Level II background screen result dated 2/24/25 and requested by the facility's human resource department, revealed prior employment at a local nursing home from 1/21/25 to 2/19/25. There was no documentation in the personnel record indicating a reference check was conducted at this facility. This was the facility where Staff A, CNA had a prior incident of physically abusing a resident. An interview was conducted with the Human Resources Director on 3/17/25 at 1:35 p.m. She stated they check the references the potential employee gives on the application and they don't cross reference with the Level II background screen. A follow up interview with the Administrator on 3/17/25 at 2:00 p.m. revealed Human Resources was checking the employment history on the application and checking those references but not checking the Level II background screen that was obtained when Staff A, CNA applied to verify other recent employment that was not listed on the application. An interview was conducted with the Administrator on 3/17/25 at 4: 00 p.m., who stated Human Resources should have at least questioned Staff A, CNA as to why she did not put her prior employment at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 2 of 3 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 03/17/2025 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 0607 Level of Harm - Actual harm Residents Affected - Few another nursing facility on her application as it was clearly on her Level II background screen. She stated if that reference was checked they might have found out about her termination and the reason for termination at the prior facility. A telephone interview was conducted on 3/17/25 at 4:35 p.m. with Staff B, CNA, who was a witness to Staff A, CNA physically abusing Resident #. Staff B, CNA stated while she and Staff A, CNA were assisting Resident #1, the resident pulled her arm back away from Staff A, CNA and Staff A, CNA grabbed Resident #1's arm and put her arm into her shirt. Resident #1 slapped Staff A, CNA and Staff A, CNA reacted by slapping Resident #1 back. Staff B, CNA stated she could clearly hear the slap in addition to seeing it. Review of the facility policy titled Abuse Neglect Exploitation and Misappropriation of Property Prevention, last reviewed 1/1/24, revealed: Intent: The facility will develop operational policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Procedure: I. Screening: Screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and /or current employers and checking with the appropriate licensing boards and registries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105660 If continuation sheet Page 3 of 3