Inspection·June 2, 2023

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 observation, interview, and record review the facility failed to ensure care and services for central venous access devices in accordance with professional standards of practice for 2 (Resident #237 and #238) of 2 residents reviewed with a central venous access devices. Residents Affected - Few Findings include: 1). During an observation on 5/30/2023 at 11:45 AM Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 5/31/2023 at 1:00 PM, Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 6/01/2023 at 8:20 AM Resident #237 was lying in bed with single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an interview on 6/1/2023 at 8:20 AM Staff C, License Practical Nurse (LPN), stated, [Resident #237's name] has a midline dressing dated 5/28/2023 with gauze under the transparent dressing. Normally IV [intravenous] dressings are changed weekly. I do not know if the dressing should be changed at a different time; dressings are done by the Registered Nurses. Review of Resident #237's admission record documented an admission date of 5/18/2023 with diagnoses that included osteomyelitis, severe sepsis with septic shock, peripheral vascular disease, and type 2 diabetes mellitus without complications. Review of Resident #237's physician's order dated 5/19/2023 read Heparin Sod (Pork) lock flush Intravenous Solution 10 unit/ml (milliliters) (Heparin Sodium (Porcine) Lock Flush) Use 1 dose intravenously one time a day for after midline flush at completion of IV antibiotic therapy. Review of Resident #237's physician's order dated 5/19/2023 read Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 1 dose intravenously one time a day for Flush line before and after IV antibiotic therapy dose. Review of Resident #237's physician's order dated 5/27/2023 documented, Ertapenem Sodium Injection Sodium Reconstituted 1 GM (gram) (Ertapenem Sodium) Use 1 dose intravenously one time a day for Osteomyelitis until 06/30/2023. Review of Resident #237's physician's order revealed no dressing change orders for midline venous device. During an interview on 6/01/2023 at 8:36 AM the Director of Nursing stated, I would have to look up when a dressing should be changed when it has a gauze under the transparent dressing. I do not see any dressing orders for [Resident #237's name] for his midline. I would have to question the unit manager to see, I am not seeing any orders. 2). During an observation on 5/30/2023 at 11:20 AM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 2 of 7 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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 During an observation on 5/31/2023 at 1:10 PM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an observation on 6/1/2023 at 8:10 AM with Staff C, LPN, Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an interview on 6/1/2023 at 8:11 AM with Staff C, LPN, stated, I am not sure if the dressing is dated 5/28/2023. I would have to look in the system to see when it was last changed. Normally midline dressings are changed weekly. Typically, LPNs do not do dressing changes it would be a Registered Nurse. Review of Resident #238's admission record documented an admission date of 5/27/2023 with diagnoses including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing as needed for Midline IV (intravenous). Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing one time a day every 7 day(s) for Midline IV. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV after medication administration. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV before medication administration. Review of the policy and procedure titled Midline Catheter Dressing Change,' revised date 2/2018, read Guidance. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is change: 2.2 Every two days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 3 of 7 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents (#71, #238, and #239) reviewed. Photographic Evidence Obtained Residents Affected - Few Findings include: 1). During an observation on 5/30/2023 at 9:39 AM, Resident #71 was observed lying in bed and not wearing her nasal cannula which was observed to be wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an observation on 6/1/2023 at 7:52 AM, Resident #71's nasal cannula was wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an interview with Staff A, Licensed Practical Nurse (LPN) on 6/1/2023 at 8:11 AM, Her tubing was not bagged. During an interview with the Director of Nursing on 6/1/2023 at 9:23 AM, Ultimately, staff are expected to bag and date all oxygen tubing. 2). During an observation on 05/30/23 at 11:20 AM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation 05/31/2023 at 1:10 PM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation on 6/1/2023 at 8:10AM with Staff C, LPN, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an interview on 6/1/2023 at 8:07AM with Staff C, LPN stated, Tubing should be dated and it should be bagged when not in used. Review of Resident #238 admission record documented Resident was admitted on [DATE] with diagnosis including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238 physician order dated 5/27/2023 documented, Oxygen: 2 Liters via NC Q HS and weekly tubing change at bedtime and every night shift every Sun (Sunday) change tubing. 3). During an observation on 5/30/23 at 11:20 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation 5/31/2023 at 9:00 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation on 6/1/2023 at 8:06 AM with Staff C, LPN, passive nebulizer mask placed on top of nebulizer machine and tubing was dated with what appear to be 2/19/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 4 of 7 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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 - Few During an interview on 6/1/2023 at 8:07 AM with Staff C, LPN stated I am not able to read the date on the tubing. The nebulizer mask should be bagged, and the tubing should be changed weekly on Sunday. Review of Resident #239's admission record documented resident was admitted on [DATE] with diagnoses including multiple subsegmental pulmonary emboli without acute cor pulmonale, dyspnea, and interstitial pulmonary disease. Review of Resident #239's physician's order dated 5/26/2023 read, Nebulizer: tubing change weekly Sunday 7p-7a every night shift Sun. Review of the policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer last reviewed 1/20/2023 read, Steps in the Procedure. 27. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 28. Change equipment and tubing every seven days, or according to the facility protocol. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 5 of 7 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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 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 observation, interview, and record review the facility failed to ensure the medication storage rooms were free from expired medications for two of two medication storage rooms. Findings include: During an observation on 5/31/23 at 10:12 AM of medication storage room one, there was one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/22, and two bottles of unopened Sterile Water with expiration date of 3/15/23. During an observation on 5/31/23 at 10:30 AM of medication storage room two, there was two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22 and one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22. During an interview on 5/31/23 at 11:00 AM the Director of Nursing stated, those items (one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/2, two bottles of Sterile Water with expiration date of 3/15/23, two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22, one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22) are expired. The Unit Managers try to do a monthly check. I don't know why those expired items were not discarded. During an interview on 5/31/23 at 11:05 AM Staff B, Unit Manager, stated, Central Supply goes through and spot checks the expiration dates. It is ultimately nursing's responsibility to ensure no expired medications are in the medication room. I do not know why there are expired items in the medication storage room. Review of the policy and procedure titled, Storage of Medication last reviewed 1/20/2023 read, Policy Interpretation and Implementation. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinue, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 6 of 7 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 105796 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgewater at Waterman Village 300 Brookfield Ave Mount Dora, FL 32757 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 (Resident #66, Resident #237 and Resident #240) of 3 residents reviewed were given 30 days to rescind the arbitration agreement. Residents Affected - Few Findings include: Review of the facility Arbitration Agreements presented to Resident #66 on 10/17/2021, presented to Resident #237 on 5/7/2023 and presented to Resident #240 on 5/21/2023, read, This agreement shall remain in full force and effect not withstanding the termination, cancellation or natural expiration of the Resident admission Agreement. If this Arbitration Agreement is not rescinded within three (3) business days of signing as provided for in the final paragraphs of this Agreement, this Agreement shall remain in effect for and shall be binding on the Facility and Resident for this and all of the Resident's other admission or re-admission to the Facility (if any) without any need for further renewal. During an interview on 6/1/2023 at 1:05 PM the Administrator stated, I spoke to the risk manager and we did have three days written in the arbitration agreement, but it should have been 30 days. Since we print documents via Docusign maybe it was a typo. In practice we don't hold Residents to that agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105796 If continuation sheet Page 7 of 7