Inspection·August 25, 2022

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1of 1 resident with a central venous access device, in a total of 36 residents, Resident #194. Residents Affected - Few Findings include: During an observation of Resident #194 conducted on 8/22/2022 at 10:30 AM Resident #194 was observed sitting in a wheelchair, there was a left upper arm midline catheter with a 2 x 2 gauze that covered the insertion site of the catheter, under a transparent dressing that was dated 8/16/2022. During an interview conducted on 8/22/2022 at 10:30 AM Resident #194 stated, I got that [right midline catheter] put in, in the hospital, they have not changed the dressing on that since I was in the hospital. During an interview conducted on 8/22/2022 at 10:30 AM Staff C, Licensed Practical Nurse (LPN) stated, [Resident #194's name] has one more dose of IV [intravenous] antibiotics, she has a midline, the dressing is within date and doesn't need to get changed. I see the gauze under the dressing. During an observation of Resident #194 conducted on 8/22/2022 at 1:45 PM Resident #194 was observed sitting in bed with a left upper arm midline catheter with 2x2 gauze under a transparent dressing dated 8/16/2022. Review of the medical record documented that Resident #194 was admitted to the facility on [DATE] with the following diagnoses: urinary tract infection, site not specified, unspecified atrial fibrillation (an irregular heart beat), essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormones). Review of the physician orders dated 8/18/2022 reads, Measure external catheter length on admission, with each dressing change, and PRN [as needed]. Change catheter dressing, change securement device q [every] week every day shift every Wednesday. Review of the physician orders dated 8/22/2022 reads, Flush line with 10 cc [cubic centimeters] NS [normal saline] before and after each dose of medication. During an observation of medication administration conducted on 8/23/2022 at 12:15 PM Staff C, LPN was observed administering 10 milliliters of 0.9% normal saline flush to Resident #194's midline catheter. Staff C, LPN cleaned the needleless connector with alcohol and immediately administered the normal saline. Staff C did not let the needleless connector dry or verify line placement (by checking for blood return) prior to administering the medication. During an interview conducted on 8/23/2022 at 12:25 PM Staff C, LPN stated, I did clean the connector, but should have verified placement. I did not let the needleless connector dry before administering the saline. During an observation of medication administration conducted on 8/24/2022 at 8:20 AM Staff B, LPN, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 2 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 cleaned Resident #194's needleless connector for three seconds and administered 10 milliliters of normal saline intravenously. Staff B did not let the needleless connector dry or verify line placement before administering the medication. During an interview conducted on 8/24/2022 at 8:25 AM Staff B stated, I should have cleaned the hub (needleless connector) longer, I should have let it dry, and checked for blood before administering the normal saline. Review of the Medication administration record documented no midline catheter dressing changes and no measurements for the external catheter length. Review of the treatment administration record documented no midline catheter dressing changes and no measurements for the external catheter length. Review of the nursing admission assessment documented no midline catheter and no measurements for the external catheter length. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, There is no documentation of the midline catheter or measurements on the nursing admission assessment and there should be. There are no measurements documented according to the orders. The dressing was changed on 8/22/2022, but should have been changed on admission if it had gauze under the dressing. Review of the policy and procedure titled, Midline Catheter Dressing Change with an approval date of 2/28/2022 reads, Considerations: 1. The catheter insertion site is a potential entry site for bacteria that may cause a catheter- related infection. Guidance: 1. Sterile dressing change using transparent dressings is performed: 1:1 Upon admission. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is changed: 2:1 upon admission, 2.2 every 2 days. 6. Assessment of the vascular access site is performed: 6.1 upon admission and during dressing changes. 8. Length of the external catheter is obtained: 8.1 upon admission. 8.2 During dressing changes. 9. Arm circumference (10 cm above the antecubital fossa) is obtained: Upon admission, then weekly. 9.4 Compare to baseline measurement to detect possible catheter - associated venous thrombus: a 3 cm increase in arm circumference and edema were associated with upper arm deep vein thrombosis. Reivew of the policy and procedure titled, Midline Catheter Flushing and Locking with an approval date of 2/28/2022 reads, Considerations: 4. Needless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter-related bloodstream infection. Guidance: 6. catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 3 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure appropriate treatment and services to prevent the possibility of urinary tract infection for 1 of 3 residents observed for indwelling foley catheters, Resident #77. Findings include: Review of the medical record documented Resident #77 was admitted to the facility on [DATE] with the following diagnoses: neuromuscular bladder dysfunction, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), type 2 diabetes mellitus, and peripheral vascular disease. Review of the physician order dated 3/17/2022 reads, Diagnosis for indwelling catheter: Neuromuscular bladder dysfunction. Change catheter as needed, size 14f [French]. Review of the Nursing Care plan reads, Ensure proper positioning of drainage tube at all times, keep drainage bag below the level of the bladder. During an observation conducted on 8/24/2022 at 7:35 AM Resident #77 was resting in bed, there was an indwelling urinary catheter bag observed on the left side of the bed lying on the floor. During an interview conducted on 8/24/2022 at 7:35 AM Resident #77 stated, My catheter hurts. During an interview conducted on 8/24/2022 at 7:53 AM Staff E, Certified Nursing Assistant (CNA) stated, I have not been in her room yet. I will check residents when I am doing rounds. Catheter bags should not be on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 4 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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** 4) Review of Resident #32's medical record documented the resident was admitted on [DATE] with the following diagnoses: COVID-19, sepsis, metabolic encephalopathy. Residents Affected - Some During an observation on 8/22/2022 at 9:32 AM of Resident #32's room it showed the resident's nebulizer mask was on top of the bedside dresser, uncovered and dated 7/25/2022. At the bedside is a concentrator with a nasal canula tubing hanging in the drawer of the bedside dresser, uncovered and dated 7/25/2022. During an interview with Resident #32 and Resident #32's spouse on 8/22/2022 at 9:33 AM he stated, I use the oxygen at night. During an observation on 8/23/2022 at 8:35 AM it showed Resident #32's oxygen and nebulizer tubing continue to be uncovered and dated 7/25/2022. During an interview on 8/23/2022 at 9:26 AM the East Wing Unit Manager confirmed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022 and uncovered. The Unit Manager stated, The tubing is supposed to be changed every Sunday by the night nurses, the tubing must be dated and covered. During an observation on 8/23/2022 at 1:30 PM it showed Resident #32's oxygen tubing and nebulizer mask are dated 7/25/2022. During an interview on 8/23/2022 at 1:30 PM Resident #32's spouse stated, I wished they would put the mask and nasal cannula in a bag because he uses them to put on his face. Review of the physician's order dated 8/23/2022 reads, Oxygen via nasal cannula at 2 lpm [liters per minute] as needed for complaint of SOB [shortness of breath]. Change oxygen tubing every Sunday (11PM - 7 AM). Order dated 8/3/2022 reads, Ipratropium-Albuterol solution 0.5 - 2.5 3mg/3 ml [3 milligrams/3 milliliters], 3 ml. inhale orally every 6 hours as needed for oxygen saturation < 88% via Nebulizer. Review of Resident #32's treatment administration record (TAR) from July 1 through July 31, 2022, revealed respiratory oxygen tubing and nebulizer mask were not changed throughout the month of July 2022. Review of Resident #32's treatment administration record from August 1 through August 24, 2022, revealed respiratory oxygen tubing and nebulizer mask were marked X all throughout August indicating the tubing and mask were not changed. During an interview with the Director of Nursing on 8/24/2022 at 3:00 PM stated, We do not have a policy specific to changing of respiratory tubing, we based it on doctors' orders. 2) An observation on 08/22/22 at 10:30 AM showed resident #61 was being administered oxygen at 2 liters/min via nasal cannula. There was no date on the oxygen tubing. An observation on 8/24/2022 at 1:10 PM showed resident #61 was not being administered oxygen. The resident was seated alone in the common area at the end of the East hallway. The oxygen tubing was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 5 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 not dated. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/24/2022 at 1:11 PM Resident #61 stated the facility turned my oxygen off yesterday and told me that they could not give me oxygen until they got permission from the doctor. I need my oxygen. Residents Affected - Some During an interview on 8/24/2022 at 1:51 PM Staff D, LPN stated, I was verbally told this resident's oxygen is as needed. Something happened yesterday and she needed oxygen. I see the order has the oxygen as routine at 3 liters dated 7/19/2022. The residents do not have paper charts. The oxygen tubing does not have a date because whoever changed the tubing did not put a date on the tubing. During an interview on 8/24/2022 at 2:00 PM Staff J, LPN stated, Until today the resident's oxygen order was for 2 liters per nasal cannula routine. Review of the physician's order sheet dated 7/19/2022 reads, oxygen by nasal cannula at 3 liters per minute routinely. 3) An observation on 08/22/22 at 11:37 AM showed the oxygen concentrator was set at 4 liters/min being administered via nasal cannula for Resident #82. The oxygen tubing was dated 8/8/2022. The nebulizer mask was on the bed uncovered/not bagged and was dated 8/8/2022. Review of physician's order for Resident #82 dated 8/1/2022 reads, Oxygen via nasal cannula at 2 liters per minute every shift. An observation on 8/23/2022 at 8:18 AM showed Resident #82 was sitting in a chair eating breakfast. The resident was being administered oxygen via nasal cannula at 4 liters/minute. During an Interview with Resident #82 on 8/23/2022 at 8:20 AM she said, I use 4 liters at night and 3 liters in the daytime, that is too high for me. Resident stated she does not adjust the oxygen rate, I do not touch that, the nurses do. During an interview on 8/24/2022 at 1:38 PM Staff B, LPN stated, The oxygen gets turned up with the CPAP [continuous positive airway pressure] and sometimes it doesn't get turned back down to the liters as ordered by the doctor. The night shift nurses are supposed to label the oxygen tubing Review of the medical record for Resident #82 documented the resident was admitted on [DATE] with the following diagnoses: COVID-19, acute respiratory failure, CHF (congestive heart failure), atrial fibrillation, GERD (gastroesophageal reflux disease), anxiety disorder, acute kidney failure, pacemaker, pulmonary hypertension. Review of the physician's orders dated 8/1/2022 reads, oxygen via nasal cannula at 2 liters per minute every shift. Monitor oxygen saturation and temperature every shift. Notify provider if temperature > [greater than] 100.4, and O2 [oxygen] saturation of < [less than] 98%. Review of the daily temperatures and daily oxygen saturation for the period of 7/30/2022 to 8/23/2022 documented the following: Oxygen Saturation: 7/31/2022 at 22:34 [10:34 PM] of 90%. 8/1/2022 at 21:39 [9:39 PM] - 97%. 8/2/2022 at 21:28 [9:28 PM] - 97%. 8/3/2022 at 07:34 AM and 10:34 AM - 92%, at 21:19 [9:19 PM] - 94%. 8/4/2022 at 07:48 AM - 91%, and at 14:20 [2:20 PM] at 92%. 8/6/2022 at 11:32 - 95%. 8/7/2022 at 20:20 [8:20 PM] - 95%. 8/8/2022 at 22:02 [10:02 PM] - 97%. 8/9/2022 at 07:20 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 6 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 - Some and at 07:35 AM - 96%. 8/10/2022 at 10:45 AM - 95%, and at 22:02 [10:02 PM] - 92%. 8/11/2022 at 12:17 PM - 96%, and at 21:08 [9:08 PM] - 95%. 8/12/2022 at 07:23 - 92%, 22:46 [10:46 PM] and 23:55 [11:55 PM] - 97%. 8/14/2022 at 01:00 AM, 07:30 AM and 13:12 [1:12 PM] - 97%. 8/15/2022 at 21:32 [9:32 PM] 92%. 8/16/2022 at 07:52 AM - 97%, and 22:29 [10:29 PM] - 96%. 8/17/2022 at 19:47 [7:47 PM] - 94%. 8/20/2022 at 11:29 AM - 92%. 8/22/2022 at 07:11 AM - 95%, and at 21:07 [9:07 PM] - 97%. 8/23/2022 at 07:11 AM - 97%. Review of Resident #82's medical record did not contain documentation of the physician having been notified of the oxygen saturations per the physician order. Based on observation, interview, and record review the facility failed to ensure residents receive respiratory care services for oxygen administration consistent with professional standards of practice for 4 of 5 residents reviewed for respiratory care, Residents #195, #61, #82, and #32 in a total sample of 33 residents. Findings include: 1) During an observation conducted on 8/22/2022 at 11:04 AM, Resident #195 was observed resting in bed with the head of his bed flat with 4 liters of oxygen being administered through a nasal cannula connected to an oxygen concentrator. The oxygen humidification bottle was empty and not dated. Review of the medical record documented Resident #195 was admitted to the facility on [DATE] with the following diagnoses, COVID-19 Viral pneumonia, liver cirrhosis, liver cell cancer, iron deficiency anemia, chronic obstructive pulmonary disease, chronic kidney disease, major depressive disorder, essential (primary) hypertension, hyperlipidemia, and status post tracheostomy Review of the physician orders dated 8/22/2022 reads, Oxygen via nasal cannula LPM (liters per minute) 2 liters every shift. During an observation conducted on 8/23/2022 at 12:03 PM, Resident # 195 was observed resting in bed with oxygen running at 4 liters through a nasal cannula connected to an oxygen concentrator. During an observation conducted on 8/24/2022 at 7:15 AM Resident #195 was observed resting in bed with oxygen being administered at 4 liters through a nasal cannula connected to an oxygen concentrator. During an interview conducted on 8/24/2022 at 7:20 AM Staff D, Licensed Practical Nurse (LPN) stated, His oxygen is set at 4 liters and that seems kind of high. Let me see what he is supposed to be set at. He should have 2 liters of oxygen running. I will usually check what oxygen is at when I give residents their medications and I just haven't had time to do his meds yet. During an interview conducted on 8/24/2022 at 11:30 AM the Director of Nursing (DON) stated, I expect that nurses will check the amount of oxygen that is running at least when they administer their medications if not more frequently. Review of Policy and Procedure titled, Oxygen Administration via Concentrator approval date 2/28/2022 reads, Purpose: To deliver oxygen to the resident using an oxygen concentrator. A licensed nurse or respiratory care practitioner performs this procedure. Procedure: Setting up the concentrator: 2. Turn to proper flow rate as ordered by the physician. Check the concentrator to assess the maximum (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 7 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 flow rate. 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: 105703 If continuation sheet Page 8 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review the facility failed to ensure posted staffing information was accurate and current on 2 of 4 residential halls and in the lobby. Residents Affected - Many Findings include: During the initial tour conducted on 8/22/2022 at 9:05 AM upon arrival into the building the staffing posted in the front lobby receptionist desk was dated 8/19/2022. During a tour conducted on 8/22/2022 at 9:15 AM of the west wing the posted staffing on the large white dry erase board was dated 8/20/2022. During an observation on 8/22/2022 at 10:45 AM, the staffing posted in the lobby at the receptionist's desk was dated 8/19/2022. During an interview conducted on 8/21/2022 at 10:50 AM the Administrator stated, The posted staffing is not correct. It was last posted three days ago and should be updated. Review of the policy and procedure titled, Nursing Scheduling/Staffing/Posting with an approval date of 2/28/2022 reads, 5. Posted staffing information & Retention a. Data requirements: The facility must post the following information on a daily basis: 1) Facility name, 2) the current date, 3) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: b. Posting requirements: The facility must post the nurses staffing data specified above on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 9 of 10 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 105703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arbor Trail Rehab and Skilled Nursing Center 611 Turner Camp Rd Inverness, FL 34453 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure the medical record for 1 of 3 residents, Resident #55, reviewed for nutrition was complete. Residents Affected - Few Findings include: Record review of Resident #55's care plan, date Initiated 02/01/21, documented Resident #55 was at risk for decreased nutritional status and dehydration related to a history of COVID-19, dysuria, cough, and difficulties with swallowing. Resident #55's care plan documented nutritional interventions to include Monitor PO [by mouth] intakes. Record review of Resident #55's Point of Care Response History for Eating Meal Percentage dated 7/26/22 - 8/23/22, failed to reveal completed documentation of the intake amounts Resident #55 consumed at each meal. Resident #55's meal intake was not recorded on 2 of 28 days, was recorded for 1 of 3 meals for 15 of 28 days and was recorded for 2 of 3 meals for 10 of 28 days. During an interview on 8/24/2022 at 8:32 AM, Staff A, Licensed Practical Nurse/West Unit Manager confirmed staff should be recording Resident #55's meal intake percentages for three meals a day. During an interview on 8/24/2022 at 10:28 AM, the Director of Nursing stated Resident #55's meal intake data had not been recorded for each meal. During an interview on 8/24/2022 at 11:40 AM, the Director of Nursing reported the facility did not have a policy specific to documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105703 If continuation sheet Page 10 of 10