Inspection·January 8, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few electronic elopement device since 08/13/20. She reported that nurses are responsible for checking the functioning and placement of the electronic elopement device. Staff H confirmed that there was no documentation related to checking the functioning and placement of the electronic elopement device in the resident's electronic or paper health record. She stated that the resident went out to the hospital in November (2020) and it has not been checked since. The electronic elopement device was originally on the left ankle. Staff H stated the functioning and the placement of the electronic elopement device should be documented in the chart. On 01/08/21 at 9:57 a.m., the DON reported that the nurses are responsible for checking the a electronic elopement devices and that it should be documented on the TAR (Treatment Administration Record) every shift by the 7 (a.m.) -11 (p.m.) nurses. The DON stated that the MDS should indicate if the resident had an electronic elopement device and the care plan should indicate that a resident had an electronic elopement device. The policy titled, Elopements and Wandering Residents, undated, revealed the following: Policy This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis or hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. 4e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105949 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 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, policy review, and review of the Food and Drug Administration (FDA) food safety guidelines, the facility failed to ensure onsite cooked food for two of two five-gallon containers of soup were cooled to 41 degrees Fahrenheit within food safety time parameters to limit, and prevent, foodborne pathogen growth. Findings included: During an observation on 01/07/21 at 10:00 a.m. with the Food Service Director (FSD), large, deep five-gallon containers were stored inside of the walk-in cooler beside the back-kitchen exit door. The FSD stated the containers held soup that was cooked yesterday on 01/06/20. The FSD retrieved a metal stem probe thermometer and measured the internal temperature of the beef stew soup; the food product measured 46.2 degrees Fahrenheit (F). The butternut squash soup, stored inside the deep, five-gallon container was measured by the FSD using the metal stem probe thermometer; the product had an internal temperature of 56.2 degrees F. During an interview on 01/07/21 at 10:05 a.m., the Chef Manager stated the process for cooling the food items stored in the large five-gallon containers is to use a cooling wand. The food product is stirred with the cooling wand until it reaches a safe temperature and then stored inside the walk-in cooler. He confirmed he oversees the cooling of cooked foods to make sure they reach a safe temperature within the appropriate timeframe. He stated he does not have a temperature tracking log. During the interview on 01/07/21 at 10:05 a.m., the Chef Manager stated cooked food items must be cooled from 135 degrees F to 70 degrees F within four hours, and then from 70 degrees F to 41 degrees F within two hours. The FSD confirmed the correct cooling process is for a cooked food item to be cooled from 135 degrees F to 70 degrees F within two hours, and then from 70 degrees F to 41 degrees F within four hours. The FSD stated the food should be separated into smaller containers and a cooling log should be used to monitor the cooling process. Both the FSD and the Chef Manager stated the soups that measured above 41 degrees F cannot be served to residents and must be discarded. During an interview on 01/08/21 03:18 p.m. the FSD provided a policy titled, Food Cooling Directive, dated January 8, 2021, and stated prior to today the facility did not have a written policy in place for the cooling of food items. A review of the Food Cooling Directive, dated 01/08/21, revealed, Pathogens grow fastest in the temperature range of 70-140, all foods must pass through this temperature range very quickly. All foods must be cooled to 70 degrees inside of 2 hours. Then these foods must reach 40 degrees or less within 6 hours Denser foods cool slower [chili, [NAME], stews, thick soups] Best ways to cool hot foods: ice water bath adding ice often as it melts, use the ice wands [keep them clean and filled] . According to the Food and Drug Administration (FDA) Food Code, dated 2017, page 94-95, revealed, Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°C [Celsius] (135°F) to 21°C (70°F), and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less Cooling shall be accomplished in accordance with the time and temperature criteria . by using one or more of the following methods . (1) Placing the food in shallow pans, (2) Separating the food into smaller or thinner portions, (3) Using rapid cooling equipment, (4) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105949 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 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 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 0812 Stirring the food in a container placed in an ice water bath, (5) Using containers that facilitate heat transfer, (6) Adding ice as an ingredient, or (7) Other effective methods . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105949 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 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility failed to create and implement a plan of action to ensure a root-cause analysis, investigation and training were completed, per their quality assurance process, for one resident (#21) of two residents sampled for accidents. In addition, the facility's failure to conduct a root-cause analysis and collect data for Resident #21 revealed current inconsistencies with hot beverage procedures among direct care staff. Findings included: A review of the Detailed Summary report revealed Resident #21 was a male with an admission date of 08/15/10. Resident #21 expired in the facility on 01/06/21 at 12:51 p.m. His Minimum Data Set [MDS], dated 10/09/20, Section C: Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating an intact cognitive state with no behaviors of inattention, disorganized thinking, or altered level of consciousness. Section F: Functional Status revealed the resident required limited assistance for eating. A record review was conducted of the facility's Incident Log- Fall/Skin/General, with a date range of 06/06/20 to 01/06/21. The document revealed Resident #21 had an injury type of a burn/scald on 12/14/20. A review of Resident #21's Interdisciplinary Notes, dated 12/15/20, revealed, Resident has spilled hot tea to his abdomen and right inner forearm at breakfast this morning. CNA [Certified Nursing Assistant] reported the happening. Resident stated he wasn't fully awake when he began to drink it. The cup did have a lid on it per CNA. Area was assessed. Area is pink with no blistering Management contacted and paperwork completed. Resident is his own person and is responsible for self. Asked that this nurse not call his family per the resident A review of Resident 21's Care Plan Historical Copy Date: 12/15/2020, revealed a Category: 16 Pressure Ulcers, . is at risk for impaired skin integrity due to arterial deficit He currently has a coffee burn to right inner forearm. Interventions included weekly skin checks, observe skin daily with care, provide treatment as ordered by the Medical Director (MD). A review of Resident #21's Skin Evaluation, origin date of 12/14/20 at 8:08 a.m. revealed a description of redness from burn to abdomen, and a treatment of Silvadene to mid-right abdomen . A review of the Skin Evaluation, origin date of 12/14/20 at 8:13 a.m., revealed a description of redness t [to] right inner FA [forearm] from burn. A review of Resident #21's Skin Evaluations by a Registered Nurse Surveyor on the state agency survey team determined the scald was first degree. During an observation on 01/06/21 at 11:57 a.m., the beverage meal cart revealed beverage cups with lids. An interview with Staff K, CNA revealed the covered beverage cups on the beverage carts are filled with coffee and allowed to cool before being passed to residents. Each floor of the building has their own coffee dispenser. During an interview on 01/07/21 at 9:30 a.m., the Food Service Director (FSD) stated the coffee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105949 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 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dispensers are set at a lower temperature on the coffee machines and monitoring of the temperatures occurs. He said, Usually the resident's complaint is that the coffee is not hot enough. During an observation on 01/07/21 at 12:00 p.m. Staff G, CNA stated the process, if a resident wants hot tea or coffee, is to get a clean cup and dispense the hot water or coffee from the dispenser. If the resident is cognitively able then, I give them the liquid and just say, hey this is hot. She stated if a resident's meal ticket indicates caution hot liquids, then she will let the beverage cool off with a lid on the beverage cup before passing it to a resident. She stated she would normally wait an average of five minutes before giving a resident a hot beverage. During an interview on 01/07/21 at 12:25 p.m., Staff I, Agency CNA stated if a resident asks for tea or coffee, I would get them it from the dispensers and pass it off and let them know it was hot. Honestly, the facility hasn't given me any education related to hot liquids, but usually I would check the meal ticket or just ask another staff member. Staff I, Agency CNA stated if a resident could not have hot liquids then she would wait 10-15 minutes before providing them with the beverage. During an interview on 01/07/21 at 2:49 p.m., Staff J, Agency CNA stated if a resident made a request for a hot beverage, she would get it for them. She said, Usually if a resident cannot have something it would be listed on their care plan, or I would look at their meal ticket, and then their care plan If their care plan or meal ticket says they cannot have a hot beverage then I would not give it to them. During an interview on 01/08/21 at 1:24 p.m. the Nursing Home Administrator (NHA) stated Resident #21 had a scald from spilling tea on himself on 12/14/20. The area the tea was spilled on was pink, but there were no additional issues observed with the scald. The NHA stated she was unable to find the event investigations that risk management should have completed for the event. She states the resident was sent to the hospital on [DATE] for an event unrelated to the scald and that may be why it was overlooked. The NHA confirmed that post the event on 12/14/20, a hot liquid evaluation was not completed for the resident per their facility protocol. The NHA confirmed she was unable to find staff educational in-servicing related to beverage temperatures. During an interview on 01/08/21 at 2:46 p.m., the MD confirmed being involved in Quality Assurance and Performance Improvement meetings with the facility. The MD stated after an event such as a scald, his expectation would be for the facility to complete a root-cause analysis, conduct investigations, and verify that processes are in place to prevent the event from happening again. A follow-up interview with the NHA and Director of Nursing (DON) on 01/08/21 at 3:29 p.m., the NHA confirmed the process for incidences is to discuss the events in the morning meeting the following day. Currently, the facility is dealing with a high turnover rate and a shortage of staffing. Along with the high turnover rate, there have been issues with the organization of documentation and the storage of facility policies and procedures. The NHA and DON confirmed the facility should have investigated, conducted audits, and provided additional staff education with a set goal date related to beverage temperatures to ensure performance improvement per their QA process post Resident #21's event on 12/14/20. A policy review of Quality Assurance and Performance Improvement (QAPI) Committee, dated July 2016, revealed, The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI program . Goals of the Committee: 1. Establish, maintain, and oversee facility systems and processes to support the delivery of quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105949 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 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of care and services; 2. Promote the consistent use of facility systems and processes during provision of care and services; 3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately, 4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems . A policy review of QAPI Data Collection System, implementation date of 2019, revealed, It is the policy of this facility to systematically collect data as part of the QAPI program . Performance Indicator is an indicator that enable staff to assess progress towards the achievement of intended outputs, outcomes, and objectives . 1. Data will be collected from all departments, residents, and family members. A. sources of data include . incident and accident reports, including reports of adverse events or abuse, neglect, or exploitation Event ID: Facility ID: 105949 If continuation sheet Page 7 of 7