Health inspection·August 7, 2025

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** Based on record reviews, observations, and interviews, the facility failed to implement an effective infection control program related to 1. Not following local public health recommendations during an investigation of a possible Legionella outbreak. 2. Failed to ensure respiratory equipment was stored in a clean and sanitary manner for two of two observations. 3. Failed to ensure staff, including providers, used appropriate personal protective equipment (PPE) to prevent the transmission of an infectious pathogen for one resident (#5) of two residents sampled for transmission-based precautions. 4. Failed to display signage identifying the type of precautions that should be used for one resident (#3) of two sampled residents.Findings included: Residents Affected - Many 1. Review of Resident #1’s clinical record showed the resident was admitted on [DATE] from an acute care facility. The record revealed the resident was admitted with diagnoses including but not limited to unspecified organism sepsis, acute and chronic respiratory failure with hypoxia, unspecified pneumonia, and unspecified chronic obstructive pulmonary disease (COPD). The resident was discharged to an acute care facility on 12/2/24 related to low oxygen saturation. During an interview on 8/7/25 at 1:42 a.m. the Executive Director (ED) reported Resident #1 was at this facility for 12 days and urine had tested positive for Legionella after being discharged . The ED stated the resident had been in and out of the hospital at least three times prior to being at this facility. The ED stated the Department of Health (DOH) had informed her of a suspected case (Legionnaires’ disease) and had conducted testing. The facility had reviewed the Water Management Plan and had implemented “some” of the recommendations made by the DOH. The ED stated she would have to look back to see what the other recommendations were. An interview was conducted on 8/7/25 at 1:28 p.m. with the Director of Maintenance (DM). The DM reported having read about Legionella, it was a bacteria in water faucets, shower heads, and could get into the (water) system. The DM reported working at this building for two years and had not done any (Legionella) testing during this time and had not done an assessment for the bacteria (Legionella). The DM stated he doesn’t necessarily monitor for Legionella and the reason for draining the water tanks was because at the last facility he was employed at it was done so he continued it. The DM stated every day water temps were taken, a couple rooms on the north side, couple rooms on the south side, a nutrition room and the two restrooms (near the lobby). He stated the temperatures are between 110° Fahrenheit (F) and 111°F and periodically takes temperatures at the mixing valve of 115-116°F and by the time it gets to where it goes it’s not that hot. The DM reported the facility had recirculation pumps which kept the water circulating (without areas of stagnation). The DM stated the lines to the showers and faucets were also kept circulating, and the DM doesn’t check temperatures in resident rooms. During the interview the ED asked the DM to report further, he stated he let the water run 10-15 minutes and changed all the aerators (in resident rooms). The (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 105693 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 105693 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charming Lakes Rehab 2020 W Lake Parker Dr Lakeland, FL 33805 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)