Health inspection·February 13, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, the facility did not ensure accurate and timely completion of resident assessments for two residents (#27 and #82) of two residents reviewed for resident assessments. Residents Affected - Few Findings included: Review of the record for Resident #27 revealed he was admitted to the facility on [DATE] and died in the facility on [DATE]. An MDS (Minimum Data Set) assessment dated [DATE] indicated the assessment was for Death in facility. The MDS assessment was completed on [DATE] but was not submitted. Review of the record for Resident #82 revealed he was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of the MDS assessments for Resident #82 revealed the last assessment submitted was an admission assessment, submitted [DATE]. An interview with Staff E, Resident Care Specialist I RN on [DATE] at 12: 21 p.m. revealed Resident #27's MDS assessment should have been submitted. Staff E, Resident Care Specialist I RN also stated the discharge MDS assessment for Resident #82 was not submitted until [DATE]. She stated there was a switch in electronic medical records in September of 2024 and they were working in two systems at the time. She also stated the assessment should have been completed and submitted. Page 1 of 13 105730 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

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** 2. Review of the record for Resident #96 revealed an original admission date of 9/23/22. Residents Affected - Some Review of Resident #96's Level I PASRR screen completed 5/24/23 revealed under Section I: PASRR Screen Decision Making, Section A: MI or suspected MI, Resident #96 had diagnoses including Depressive Disorder and Other ( Specify ): PTSD. The Level I PASRR showed the resident did not have a diagnosis or suspicion of a SMI or ID and a Level II PASRR was not required. A behavioral health note for Resident #96 dated 10/30/24 and entitled Diagnostic Evaluation was reviewed. The Primary diagnosis listed was Post Traumatic Stress Disorder, Chronic The reason for referral/presenting problem was documented as Resident #96 was referred to psychology due to having a diagnosis of PTSD. He has nightmares, difficulty with sleeping. General comments indicated, He as a [diagnosis] of PTSD. He states he has dealt with it for many years. He will wake up from having nightmares and has difficulty with going back to sleep. Does not happen every night He does not have depression. He gets anxious when he has the nightmares or hears a very loud noise he does not expect. He knows to take deep breaths and redirect his thoughts. During an interview on 2/12/25 at 3:53 p.m., the Director of Nursing (DON) stated Resident #96 has PTSD. She stated he does not qualify for needing a Level II PASRR screening because he is stable and does not exhibit any behaviors. Based on record reviews and interviews, the facility failed to obtain an accurate Pre-admission Screening and Resident Review (PASRR) screen prior to a re-admission for one (#98) resident of thirty sampled residents and failed to ensure residents with Mental Illness or Suspected Mental Illness were referred for Level II screening for two residents (#96 and #15) of thirty sampled residents. Findings included: 1. Review of Resident #98's census information revealed the resident was admitted on [DATE], discharged on 7/14/24, and re-admitted [DATE]. Review of Resident #98's admission Record revealed the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record did not include any mental health diagnoses. Review of Resident #98's Level I PASRR screen dated 7/3/24, did not show the resident had any Mental Illness (MI), Suspected Mental Illness (SMI), Intellectual Disability (ID), or Suspected Intellectual Disability (SID). The PASRR included in the resident record revealed the resident did not require a Level II PASRR screen. Review of Resident #98's July 2024 Medication Administration Record (MAR) showed the resident was prescribed Xanax 0.25 milligram (mg) tablet every 24 hours as needed for anxiety for 14 days. The documentation revealed the resident received psychotropic medication four of twelve days. The MAR showed staff monitored the anti-anxiety behaviors of the resident and behaviors were observed on 7/12/24. 105730 Page 2 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0645 Review of Resident #98's care plan revealed the following focuses with initiation dates: Level of Harm - Minimal harm or potential for actual harm - 1/21/25, revised 1/27/25: Resident is a risk for adverse reactions related to (R/T) psychotropic medication use of antianxiety secondary to anxiety. Residents Affected - Some - 1/30/25: Resident has a behavior problem related to (r/t) making self-vomit by placing fingers down throat. Review of Resident #98's January MAR showed the resident received Buspirone 5 mg twice daily for anxiety, started on 1/20/25 and was prescribed Xanax 0.25 mg on 1/20/25 every 24 hours as needed for anxiety for 14 days. The resident received Xanax 0.25 mg three times during the month of January. Review of the Post-Traumatic Stress Disorder (PTSD)/Substance Abuse Screening Tool dated 1/21/25 revealed the resident did not experience any traumatic events or had a current or history of substance abuse. Review of the PTSD/Substance Abuse Screening effective 2/10/25 at 3:10 p.m. showed the resident reported experiencing physical abuse, felt numb or detached from people, activities, or their surroundings, and had a current or history of substance abuse disorder. Review of an updated Level I PASRR on 2/10/25 completed by the Director of Nursing (DON) of the facility showed Resident #98 had diagnoses of anxiety disorder, depressive disorder, adjustment disorder, and history of PTSD. The PASRR showed the resident was not receiving current services, had not previously received, or had been referred to MI services. The findings were based on documented history, medications, and individual, legal representative, or family report. The screening revealed the resident did not have any indications of a disorder resulting in functional limitations in major life activities appropriate for developmental stage, or had any issue with interpersonal functioning, concentration, persistence, and pace, or adaption to change. The updated Level I PASRR showed the resident did not have a diagnosis or suspicion of a SMI or ID and a Level II PASRR was not required. 3. Review of Resident #15's admission Record revealed an original admission date of 5/24/18 with readmission on [DATE]. Resident #15's diagnoses included anxiety disorder (initiated 6/1/21), major depressive disorder (initiated 6/1/21), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (initiated 1/7/25), and adjustment disorder with mixed anxiety and depressed mood (initiated 1/7/25). Review of Resident #15's Level I PASRR screen dated 1/3/25, showed in Section I: PASRR Screen Decision-Making, section A. MI (Mental Illness) or Suspected MI (check all that apply): Anxiety Disorder, was checked. Depressive Disorder was not checked. Section II: Other Indications for PASRR Screen Decision-Making revealed a Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease), and a suspicion or diagnosis of a Serious Mental Illness. Under Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. During an interview on 2/12/25 at 3:54 p.m., the DON stated Resident #15's PASRR Section I has 105730 Page 3 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0645 Level of Harm - Minimal harm or potential for actual harm Anxiety marked. She reviewed the resident's diagnoses in the Electronic Medical Record (EMR) and stated he has Depression, Anxiety, and Dementia. She stated a Level II screen is not needed because his dementia diagnosis is not a primary or a secondary diagnosis. Review of the facility's undated policy titled PASRR Guidance revealed the following: Residents Affected - Some Purpose: A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness (MI) or intellectual disability (ID) for resident review. To ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need and the most appropriate setting, when a significant change in their status occurs. Guidance: As part of the preadmission screening and resident review PASRR process, the facility is required to notify the appropriate state mental health authority of our state intellectual disability authority when a resident with a mental disorder or intellectual disability has a significant change in their physical or mental condition. The nursing facility must notify the state mental health (SMH) /ID authority of significant changes in residents with MD or ID independent of the findings of the Significant Change in Status Assessment (SCSA). PASRR level 2 functions as an independent assessment process for this population with special needs, and parallel with the facilities assessment process. The facility should know their state PASRR policy on referral to the SMH/ID authority, so that these authorities may exercise their expert judgment about when a level 2 evaluation is needed. Referral to the SMH/ID authority should be made as soon as the criteria is indicative of a significant change or evident- the facility should not wait until the SCSA is complete Referral for PASRR level 2 resident review evaluation is required for individuals previously identified by PASRR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. 105730 Page 4 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assist and provide activities per preference to one resident (#71) of thirty sampled residents. Residents Affected - Few Findings included: On 2/10/25 at 10:31 a.m., an observation and interview was conducted with Resident #71. The resident stated the facility does not ask them to go to activities, because I would probably go. On 2/12/25 at 2:05 p.m., Resident #71 was observed sitting in a wheelchair in a room with a television playing. The resident reported being unaware of an activity calendar in the room. The resident stated they would go to activities, but staff don't tell her. Observation of resident room showed a calendar placed approximately four and a half feet from the floor on a bulletin board in the room. An interview was conducted on 2/12/25 at 2:07 p.m. with Staff A, Certified Nursing Assistant (CNA). The staff member stated Resident #71 does not go to activities but goes to therapy. Staff A, CNA reported the activity department goes into the resident's room to see the resident. Review of Resident #71's admission Record revealed the resident was originally admitted on [DATE]. The record included diagnoses of unspecified anxiety disorder, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, adult failure to thrive, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #71's Care Plan revealed the resident required invitations, assistance, and some encouragement to attend programs of interest and enjoyed music programs, entertainment, card games, watching television, movies, and social visits, initiated on 12/23/24 and revised on 1/21/25. The interventions included: offer seating close to program leader, provide 1:1 leisure visits of potential interest, provide activity calendar (and) review as needed, provide invitations and offer assistance to programs of assessed interest, and provide set up with activities (and) assist as needed and encourage active participation. Review of Resident #71's Activities Evaluation, effective 12/23/24, revealed the resident had personal strengths: cooperative, cheerful, leisure interests, able to make needs known, and sense of humor. The resident was able to read, write, and speak/comprehend English. The evaluation revealed the resident needed encouragement to participate in activities and the activity environment was groups, own room, day/activity room, inside facility/off unit, and outdoor. The resident's current or past interests included cards, games, arts/crafts, music, shopping, conversation, watching TV, watching movies, political interests, hobbies, and special interests. The sensory adaptations to participate needed assistance, needed reminders, and needed glasses (optical). The resident required assistance for getting to and from activity areas. The consideration comments revealed the resident was a prior resident, alert and oriented with some confusion noted at time of evaluation, was currently room-bound at the time of evaluation, some hearing impairment, and enjoyed music programs, entertainment, card games, watching television and movies, and social and pet visits. Review of Resident #71's Activities Evaluation, effective 1/19/25, showed the resident had no changes noted with activity preferences and staff would continue to assist as needed. 105730 Page 5 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #71's Minimum Data Set (MDS) assessment dated [DATE] revealed under Section F Preferences for Customary Routine and Activities, being around pets, doing things with groups of people, doing favorite activities, and going outside for fresh air was very important and listening to music and keeping up with news was somewhat important to the resident. Section GG - Functional Abilities showed the resident used a wheelchair for mobility and had a range of motion impairment to one side of the upper extremity and one side of lower extremity. Resident #71's Brief Interview of Mental Status (BIMS) assessment dated [DATE] revealed a score of 6/15, indicating severe cognitive impairment. Review of Resident #71's Activity Task documentation for 30 days prior to 2/13/25 revealed the resident had no participation in books and poetry, creative activities, enrichment, games, holiday/special events, women club, physical activity, Resident 1:1 individual participation, resident council/empowerment, sensory, social/discussions/cognitive, spiritual, trips/outings, and/or virtual visitation (14 day look back). The documentation showed the resident participated in entertainment on 1/22/25 at 2:59 p.m., participated in friendly visit/room visit and independent leisure pursuits on 1/22/25 at 2:59 p.m. and on 2/10/25 at 2:59 p.m., and participated in self-image/nail care on 2/10/25 at 2:59 p.m. An interview was conducted with the facility's Activity Director (AD) on 2/13/25 at 9:19 a.m. The AD reported Resident #71 was here for rehab and was admitted to the facility a couple of times before. The staff member reported the resident attended the music program yesterday 2/12/25 between 3-4 p.m. and went to a hair appointment. The AD reported documentation was done electronically in the resident's record. A review of Resident #71's Activity Tasks revealed no documentation of the resident's participation in the music program or any music program in the last 30 days. The AD stated she would have to make a late entry for the resident's participation in 2/12/25 music program. The staff member stated the resident was on isolation and did not know what type (per physician order: Contact precautions from 12/21/24 to 1/6/25) and when the resident was unable to come out of room at the time. The AD stated when resident's first come in, the department does initial evaluations and if the resident's come for short-term/rehabilitation, the department goes around the building to invite them, calendars are placed in each room and lobbies, and during resident council she attempts to get ideas to either add or subtract activities. The AD stated, we can do better documentation. An interview was conducted on 2/13/25 at 10:16 a.m. with the facility's Director of Nursing (DON). The DON stated the facility does welcoming meetings, shows new resident's the activity calendar, and the Activity Department follows up the calendar throughout the day. Review of the February Activity calendar revealed activities are provided daily from morning to afternoon and to early evening on certain days. Review of the policy - Individual Activities, copyright 2021, showed Individual activities are provided for those residents who do not wish to attend group activities. The Procedure revealed: 1. Individual activities are provided because residents have a need for personal identity. Some residents are unable to do or do not wish to participate in Group activities. 2. For those residents who do not wish to participate in Group activities, the activity program provides individual activities that: 105730 Page 6 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0679 - Make maximum use of each resident's physical and mental abilities; And Level of Harm - Minimal harm or potential for actual harm - Are interesting to and involve the resident, and which presents a challenge that can be met by the resident. Residents Affected - Few 105730 Page 7 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations and interviews, the facility failed to ensure appropriate cautionary and safety signs indicating the use of oxygen were posted at 23 out of 23 randomly observed rooms where oxygen was administered. Residents Affected - Some Findings include: During an observation on 2/11/2025 at 2:59 PM, 23 resident rooms where oxygen was observed administered had no oxygen use signage near the resident rooms. During an observation on 2/12/2025 at 4:00 PM, the facility had no smoking signs posted outside the facility next to the front entrance door, but there were no signs addressing the use of oxygen inside the facility. During an interview on 2/13/2025 at 11:45 AM, the Nursing Home Administrator and the Director of Nursing stated the facility did not need oxygen signs on resident doors because they had no smoking signs posted outside the facility. During an interview at 12:00 PM on 2/13/2025 with the [NAME] President of Clinical Services, she stated they were told by life safety they did not have to put oxygen signs outside resident rooms where oxygen is administered because they have no smoking signs posted on the oxygen storage rooms located in the facility. The facility did not have an oxygen policy related to oxygen signs. Photographic Evidence Obtained 105730 Page 8 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to coordinate communication with a Dialysis center for one resident (#36) of one resident sampled for Dialysis services. Residents Affected - Few Findings included: On 2/12/25 at 12:32 p.m., Resident #36 was observed lying in bed with a lunch tray on the overbed table next to the bed. The resident reported not feeling well and may not go to Dialysis. The resident also stated she has not missed any Dialysis appointments and the facility provided transportation to the Dialysis center. Review of Resident #36's admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses of end stage renal disease (ESRD) and dependence on renal dialysis. Review of Resident #36's February 2025 physician orders showed the resident was to receive Hemodialysis three times a week every Monday, Wednesday, and Friday. An interview was conducted on 2/11/25 at 3:41 p.m. with Staff B, Registered Nurse (RN). The staff member stated a face sheet, list of medications, and the communication form was sent to the Dialysis center for dialysis appointments. Staff B, RN also stated the communication forms are filled out before the resident leaves and after the resident returns. They are scanned into the medical record and put into the Dialysis binder. Review of Resident #36's Dialysis Communication forms revealed the Dialysis center did not complete the portion reserved for them to complete, showing any medications given during/after treatment, pre-treatment and post-treatment weights, pre-treatment and post-treatment vital signs, any access problems, snacks/fluids given, any change in condition, or special instructions/comments on 1/24/25, 2/3/25, 2/5/25, and 2/7/25. An interview was conducted with Staff C, Licensed Practical Nurse (LPN)/Unit Manager (UM) on 2/11/25 at 3:48 p.m. Staff C, LPN UM reviewed the Dialysis Communication forms and stated, Guess when these come back without the center information I should have been asking them to complete them. The staff member stated the four forms missing the Dialysis center information were ones in back of the book and explained that was why she liked to scan them in so they didn't get put back behind the physician orders. Review of Resident #36's Progress Notes on 1/24/25, 2/3/25, and 2/5/25 did not reveal the facility attempted to contact the Dialysis center for information regarding the resident's treatment. The facility did not provide Progress Notes for 2/7/25. An interview was conducted with the facility's Director of Nursing (DON) on 2/12/25 at 12:05 p.m. The DON reported they have been having a terrible time getting the Dialysis center to return the Communications forms and they keep calling the center, but they don't receive them. The DON stated she contacted the facility's corporate office and the facility does not have a policy for Dialysis. Review of Resident #36s Dialysis Communication Forms dated 2/5/25 and 2/7/25, sent to the facility 105730 Page 9 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0698 Level of Harm - Minimal harm or potential for actual harm by the Dialysis center on 2/12/25 at 10:33 a.m. revealed the completion of the Dialysis Center information, however it did not contain pre or post treatment facility information. The form dated 2/5/25 showed the resident received 100 milligrams of iron during or after the treatment and on 2/7/25 the resident received 100 milligrams of iron and 75 micrograms of Mircera, a long-acting erythropoiesis-stimulating agent (ESA) used for the treatment of anemia (www.mircera.com). Residents Affected - Few Review of the contract between the facility and Dialysis Center, effective May 18, 2017, included the following: 2. Interchange of Information. The Nursing Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents, including a Registered Nurse as a contact person at the Nursing Facility. Those responsibilities include oversight of provision of services to the ESRD residents. B. Obligations of the ESRD Dialysis Unit and/or Company. 1. Standards of ESRD Dialysis unit. The ESRD dialysis unit shall conform to standards not less than those required by any applicable laws and regulations of any local, state or federal regulatory body, as the same may be amended from time to time. D. To provide to the Nursing Facility information on all aspects of the management of the ESRD Resident's care related to the provision of Services, including directions on management of medical and non-medical emergencies, including, but not limited to bleeding, infection, and care of dialysis access site. D. Mutual Obligations. 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Nursing Facility and ESRD Dialysis Unit. Documentation shall include, but not be limited to, participation in care conferences, continual quality improvements, and review of infection control of policies and procedures, in the signatures of team members from both parties on a short term care plan (STCP) and long term care plan (LTCP). Team members shall include the physician, nurse, social worker, and dietician from the ESRD dialysis unit and a representative from the nursing facility. 105730 Page 10 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and policy review, the facility failed to ensure medications were stored in a safe manner and inaccessible to unauthorized personnel, visitors, and residents on two (800-hall and 200-hall) of seven medication carts. Findings included: On 2/12/25 at 8:49 a.m., an observation was conducted with Staff F, Licensed Practical Nurse (LPN) of medication administration. On 2/12/25 at 9:13 a.m. after the observation of medication administration with Staff F, LPN, an observation was conducted of a thermal cooler sitting on top of the medication cart of the 800-hall with a bottle of over-the-counter medication handwritten labeled Lacto Probiotic. The staff member stated the Lacto was left unattended on the medication cart, but it had to stay refrigerated during the medication pass. On 2/12/25 at 11:41 a.m., an observation was conducted with Staff D, LPN obtaining a blood glucose level and the administration of insulin aspart for Resident #246. The staff member moved the medication cart from the doorway outside of the resident's room to the nursing station where the amount of insulin was verified with Staff C, LPN/Unit Manager. The amount of insulin was verified, the insulin pen was placed in a pharmacy labeled bag, and the medication cart was moved back to the area outside of the resident room, approximately half the medication cart was unseen from the resident room. The staff member entered the resident room, leaving the medication cart unlocked, with the insulin pen and administered the medication while standing over the resident. The medication cart was not visible to staff during the administration. An interview was conducted on 2/13/25 at 12:58 p.m. with the Regional Nurse Consultant (RNC). The RNC stated medications should not be left unattended on top of medication cart. Review of the policy titled Storage of Medications, revised August 2014, showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The Procedure of the policy revealed only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the policy titled Medication Pass Guidelines, copyright 2008, revealed during the administration of medication Lock medication cart when not in direct view of nurse administering medication. 105730 Page 11 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility did not ensure timely isolation precautions were initiated for one resident (#345) out of 39 residents sampled. Residents Affected - Few Findings included: A review of Resident #345's admission Record showed an admit date of 2/7/2025 with a primary diagnosis of periprosthetic fracture abound internal prosthetic left hip joint, subsequent encounter. On 2/10/2025 at 9:50 a.m., an observation and interview was conducted with Resident #345 in the resident's room. Resident #345 stated he was in the facility for rehabilitation after hip repair surgery. Resident #345 had two dressings on his left lower extremity. Resident #345 did not have any signage indicating the resident was on Enhanced Barrier Precautions (EBP). On 2/11/2025 at 12:45 p.m., an interview was conducted with the Assisted Director of Nursing/Infection Control Preventionist (ADON/ICP). The ADON/ICP stated all residents with any wounds, including surgical wounds, should be on EBP. On 2/12/2025 12:22 p.m., a follow up interview was conducted with the IPC related to Resident #345. The IPC stated based on Resident #345's surgical wounds, the resident should have been placed on EBP upon admission. On 2/13/2025 09:34 a.m., an interview was conducted with the Director of Nursing (DON), who stated she was aware of the lack of EBP for Resident #345 and stated, we have a great deal of turn around with admits and discharges and we could be doing a better job. A review of the facility's policy and procedure titled Isolation - Precautions Overview: SNF (Skilled Nursing Facility) and ALF (Assisted Living Facility), copyright 2013, showed the following Purpose statement: - To provide a system of isolation precautions to prevent the transmission of infection. - To prevent the transmission of infectious diseases. The policy also revealed the following Procedure: Enhanced Barrier Precautions - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident area activities. EBP are used in conjunction with standard precautions and expand the use of PPE (personal protection equipment) to donning gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug-resistant organisms) to staff hands and clothing. EBP are indicated for residents with any of the following: - Infection or colonization with a CDC-targeted (Centers for Disease Control and Prevention) MDROs when Contact Precautions do not otherwise apply; or 105730 Page 12 of 13 105730 02/13/2025 Spring Lake Rehabilitation Center 1540 6th St NW Winter Haven, FL 33881

F 0880 - Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105730 Page 13 of 13