Inspection·February 3, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the baseline care plan for 2 of 6 current newly admitted sampled residents was completed within 48 hours of admission (Residents #1 and #13). The findings included: 1) Review of the record revealed Resident #1 was admitted to the facility on [DATE]. Further review of the record revealed the baseline care plan was completed on 01/14/22 by the Minimum Data Set (MDS) Director. During an interview on 02/02/22 at 12:33 PM, the MDS Director stated she was responsible for the completion of the baseline care plans and further volunteered, sometimes they are a little late. The MDS Director explained that she works Monday through Thursday, so if a resident was admitted over the weekend, it would be completed late. When asked if someone does them on the days that she is not working, and she shook her head no. During an interview on 02/03/22 at 3:49 PM, the Director of Nursing (DON) stated they identified the issue related to baseline care plans and provided an in-service to the nurses on 02/01/21. At that time, they started having the Registered Nurses complete the baseline care plans. The DON stated they did a subsequent in April 2021 and found that it still wasn't working all the time, so now it is back to having the MDS Director do the baseline care plans. The DON was made aware the survey team identified non-compliance as recent as this past month (January 2022). 2) Record review revealed Resident #13 was admitted to the facility on [DATE]. Further record review revealed the baseline care plan was completed on 12/29/21. During an interview on 02/03/22 at 12:30PM with the MDS Coordinator, she was shown the date on the baseline care plan for Resident #13, and she acknowledged the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 2 of 4 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 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to complete a performance review of every Certified Nursing Assistant (CNA) at least once every 12 months for 2 of 9 sampled employees (Staff C and D) Residents Affected - Few The findings included: An employee roster was provided by the facility on 01/31/22. Two of nine CNAs who have worked at the facility at least one year were sampled, with hire dates of 02/21/2020 (Staff C) and 06/05/2020 (Staff D). A request was made for each CNAs last performance review. An interview was conducted with the Human Resources Director on 02/02/22 at 01:22 PM. The Human Resources Director stated the Director of Nursing (DON) conducts situational education throughout the year, but does not have a documented evaluation. She was previously completing evaluations but stopped with everything else going on at this time. No documentation of an annual performance review was provided for Staff C and D. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 3 of 4 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 106097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to inform residents, their representative, and families of those residing in facilities by 5 PM, the next calendar day, following the occurrence of additional confirmed infections of COVID-19, during the past 2 of 2 outbreaks of the virus (August of 2021 during the Delta variant outbreak and December of 2021 during the Omnicron variant outbreak). Residents Affected - Some The findings included: During an interview on 02/01/22 at 2:38 PM, the Director of Nursing (DON), who was also the Infection Control Preventionist (ICP), was asked about notification of positive COVID-19 cases to residents and families. The DON stated they do Robo-Calls to the families. When asked about notification to the alert and oriented residents, the DON explained they would verbally let them know, like when we are testing them, we would explain they are being tested because they had a positive staff. When asked if notification to the residents was being documented in any way, the DON stated it was not. The DON was asked to provide evidence of the most current Robo-Call to the representatives and families, and what was said on the recording. On 02/01/22 at 4:01 PM, the DON stated they were having trouble printing out what was being said on the Robo-Call. The surveyor went into the office of the Human Recourses Director to listen to the call. The date of the recording on her computer was 12/28/21 at 11:22 AM and was titled Omnicron Announcement. When asked for notification from the 01/20/21 positive staff, the DON explained that they do the notification at the beginning of the outbreak, but not with each positive case. Listening to the recording, the Administrator announced that they have one new staff case and that they were now in outbreak status. The DON stated they did not notify the residents and families with each of the positive COVID cases (staff and or residents) that they had with the previous Delta variant outbreak in August of 2021. Review of the current staff census used by the DON to track testing, revealed they had positive staff COVID-19 testing results as follows: On 12/28/21 there were three positive staff. Note the recorded notification mentioned just one positive case. On 12/29/21, 12/30/21, 01/01/22, 01/02/22, and 01/04/22 there was one positive staff on each of those days. On 01/11/22 there were three positive staff. On 01/12/22, 01/18/22, and 01/20/22 there was one positive staff on each of those days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106097 If continuation sheet Page 4 of 4